JBGK ACADEMY REGISTRATION

Participant Information

NAME

First Name Last Name

Birth Date

Month Day Year

Club currently representing

Address

Street Address
Street Address Line 2
City	Province
Postal Code	Country

Parent/Guardian Information

Name

First Name Last Name

Home Number

Area Code Phone Number

Cell Number

Area Code Phone Number

E-mail

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by JBGK ACADEMY during the selected sessions. In exchange for the acceptance of said child’s candidacy by JBGK ACADEMY, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless JBGK ACADEMY, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against JBGK ACADEMY, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including soccer. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Confirmation

BY ACKNOWLEDGING AND CLICKING SUBMIT BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

After reviewing our schedule please choose the sessions you would like to attend. *

All Bookings must be make at least 48 hours prior to the sessions.

If you wish to cancel or change the date of a session you book please send an email to info@justinebernier.com. You can change your session with at least a 24 hour notice.

What are you registering for?

Spring Session Package U7-U11 - 460$ Spring Session Package U12-U17 - 520$ Spring Collegiate Prep. Program - 800$ March Break Camp 300$ 1 Private Session 70$ 3 Private Sessions 200$ 5 Private Sessions 300$ Special Training Options (will contact info@justinebernier.com)

Please choose Payment Method

By Cheque to Justine Bernier Online by credit card (paypal to info@justinebernier.com) email transfer to info@justinebernier.com

If you clicked one of the payment by cheque options or email transfer option, please send and email to info@justinebernier.com confirming which option you choose, for payment arrangements and scheduling Registration form must be filled and submited regardless. Your registration will only be considered valid after payment has been received and this form has been submitted.

Thank You,

Justine Bernier

JBGK REGISTRATION FORM