Elementary After School Registration and Payment

Participant Information

Child's Name

Full Name *

Birth Date * +

Grade *

Child 2 (If Applicable)

Full Name

Birth Date +

Grade

Child 3 (If Applicable)

Full Name

Birth Date +

Grade

What Pre School or Elementary School does your Child Attend? *

Ketterlinus (MONDAY 3pm-4pm)

Select all that apply:

Ketterlinus Basketball 4/17-5/22 6 weeks $120

Second Child Basketball$110

Wards Creek Elementary (Tuesday 3pm-4pm & Wednesday 2pm-3pm)

Select all that apply:

Wards Wiffle Ball **NEW** 4/11-5/23 (Tuesdays) 7 weeks $140

Second Child Wiffleball $130

Wards Flag Football 4/12-5/24 (Wednesday) 7 weeks $140

Second Child Flag Football $130

Cunningham Creek (Thursdays 3pm-4pm)

Select all that apply:

Cunningham Creek Wiffle Ball **NEW** 4/13-5/18 6 weeks $120

Second Child Wiffle Ball $110

Timberlin Creek (Fridays 3pm-4pm)

Select all that apply:

Timberlin Creek Basketball 4/14-5/19 6 weeks (closed)

Second Child Basketball $110 (closed)

Early Bird Special Expires 12/15 Coupon Code:

Enter Coupon Here (Expired)

Current Total:

$0.00

Adult Primary Contact 1

Relationship to Participants: *

Parent

Guardian

Other Other

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Email *

Adult Primary Contact 2

Relationship to Participants:

Parent

Guardian

Other Other

First Name

Last Name

Address 1

Address 2

City

State

Zip

Phone

Email

Emergency Contact

Emergency Contact 1 *

Phone *

Emergency Contact 2

Phone

Primary Care Pediatric Contact

Doctor's Name *

Phone *

Does your child have any allergies? (N/A for none)

Waiver

Parent or legal guardian must sign below before acceptance into program. As parent/legal guardian of the child named herein, I hereby represent that the child has been deemed physically fit by his/her pediatrician to participate in Sports instruction. I understand that there are inherent risks in participating in this athletic program. I hereby accept responsibility for and agree to pay any and all costs of medical treatment resulting from any injury suffered by my child as a result of his/her participation in all physical activities with Sports & Arts. I understand that all enrollments are final and no refunds will be issued once payment is made. I further agree to indemnify and hold harmless Sports & Arts LLC and any of their coaches from any and all liability, damage, cost or expense arising out of my child's participation of every kind and nature. In the event that I cannot be reached in an emergency, I hereby give permission for the care to be administered by Sports & Arts staff, EMT, physician / staff of hospital or any other qualified individual to provide medical treatment deemed necessary for my child. As well, I give permission to communicate with me via text and email and to take pictures and/or videos of my child for advertising and marketing purposes. *

Waiver

Parent or legal guardian must sign below before acceptance into program. I agree to release Sports and Arts LLC and its Employees from any and all liability for the unintentional exposure or harm due to the Coronavirus (COVID-19). Furthermore, I understand that my name and contact information might be shared with the state health department if a client or person at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department. *