Program Registration Form

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Please complete the registration form

Email *

Are you a new or existing customer? *

I am a new customer

I am an existing customer

What program would you like to register for? *

Please enter the product number

Supplemental Training Clinic- Technical Touches & Dribbling Training

Supplemental Training Clinic- 1v1 Dribbling & Finishing Training

Supplemental Training Clinic- Fitness, Speed, Agility & Quickness

Other:

Participant's Name *

Participant's Age *

Participant's Date of Birth *

YYYY

Parent / Guardian Name *

Home Address *

City *

State *

Zipcode *

Cell Phone Number *

Home Phone Number *

Work Phone Number

Email Address 1 *

Email Address 2

Emergency Contact Name *

Emergency Contact Phone Number *

Health Insurance Provider *

Health Insurance Policy Number *

Please indicate any pertinent previous Medical History *

List Medications, Allergies or any other notes *

Hold Harmless: The undersigned, Parent/Guardian of minor, understands that participation in the camp is voluntary. Parent/Guardian of minor understands that minor, as a participant in events sponsored by, or associated with Stainton Sports Enterprises, LLC., whether athletic or social in nature, is subject to risk of injury. Parent/Guardian agrees to defend, indemnify and hold harmless Stainton Sports Enterprises, LLC., and its partners, agents, employees, owners from and against any claim, demand, suit, judgment, cost of fees, which arise out of or are in any way connected with Stainton Sports Enterprises, LLC., regardless of whether such claims are the result of the negligence of Parent/Guardian/Minor or anyone else or for any other cause.Permission for Emergency Care:As the parent/legal guardian, I request that in my absence, the named participant be admitted to any hospital or medical facility for diagnosis and treatment. In case of injury, accident or illness, I authorize the on-site staff and volunteers to provide appropriate medical assistance or if an emergency transport is deemed necessary, I authorize the same summon an ambulance to transport the participant to the hospital or nearest facility. I also understand that if ambulance transport or emergency treatment is deemed necessary, I may not be notified until after the transport has been initiated. I request and authorize physicians, athletic trainers, technicians, first aid personnel, nurses to perform any diagnostic procedures, treatment procedures, operative procedures, and x-rays of the above. I have been given no guarantee as the results of examination or treatment. I and our insurance carrier accept any and all responsibility for all costs associated with the medical care of the above participant. I will notify Stainton Sports Enterprises, LLC. if at any time our medical insurance provider changes while participating in the activities with Stainton Sports Enterprises, LLC.I have read and understand the above. *

I have read, understand, and agree to the above Hold Harmless.

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