Play Action Dance & Fitness LLC                    Program & Class Registration
Membership, Program & Class Registration form
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Head of Household: Name, Age & Date of Birth *
Adult Participate: Name, Age & Date of Birth
Child Participate:  Name, Age & Date of Birth
Child Participate:  Name, Age & Date of Birth
Child Participate:  Name, Age & Date of Birth
Child Participate:  Name, Age & Date of Birth
Street Address *
Telephone Number: HOME *
Telephone Number: CELL *
Telephone Number: WORK or OTHER
Email Address
Emergency Contact (Please include name, telephone number and relation) *
EMERGENCY MEDICAL INFORMATION: Preferred Hospital *
Physician's Contact Information (Please include Name & Telephone number) *
Insurance & Policy# *
Please thoroughly list and explain any allergies and/or medical conditions of the participant(s). If more than one participant please state their name in the explanation. *
All information is true to the best of my knowledge. By singing this I agree to pay the fees associated with CAPT. I will  communicate in writing to the CFO of Play Action Sports DeBorja Brantley at iamplayaction@gmail.com, if any hardship  occur that will hinder me from paying my monthly or parade fees. I understand if I get behind (1) One month in my CAPT.  Payments, my child cannot attend classes. I understand that my child will be respectful at all times. I understand that I will  remain a role model for my child by acting professional in unprofessional situation or circumstance to the best of my ability.  This is an agreement that states my child will be a member of CAPT &/or any other dance or fitness program for the present season 2021-2022. I will be  committed to the program's / CAPT functions, parades, shows and competitions, I will abide by the program's (CAPT’s ) codes, rules, and  policies. I understand if my child becomes disrespectful, fight, steal or if any of the above statements are not followed at any  time he or she can and will be dismissed from CAPT/ CAPT Summer Camp &/or dance/fitness program. *
Required
Please Select Your Class *
Required
Play Action Sports, Dance & Fitness, LLC and  CAPT. Community Action Parade Team Contact: Coach Dee @ 678-861-7529  E-mail-thecaptaction@gmail.com RELEASE, INFORMED CONSENT & WAIVER AGREEMENT FOR  MEMBERS, GUESTS AND PROGRAM PARTICIPANTS  THE PROMISE WE STAND BY  Play Action Sports, Dance & Fitness, LLC and CAPT. Community Action Parade Team endeavors to provide a safe environment and  programs for you, your family and guests. PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION  PARADE TEAM provides exciting, life changing programs that involve exercise, travel, learning, and sports. These programs have a  certain amount of risk associated with them. This form is to make you aware of those risks and to ask that you assume certain responsibilities for your decisions and actions.  YOUR WELL-BEING AND HEALTH  • I understand I am engaging voluntarily in PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION  PARADE TEAM exercise, physical activity and/or recreational programs.  • It is my responsibility to monitor my own condition throughout any activity or program and, should any unusual symptoms occur, I  will cease my participation and inform the instructor and/or staff of the symptoms.  • In the event that a medical clearance must be obtained prior to my participation in a physical activity program, I agree to consult  my physician and obtain written permission from my physician prior to the commencement of any program. I agree to assume the natural  risks associated with exercise and physical activity.  FOR YOUR SECURITY  • I understand PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM parking lot and  locker rooms of our sites which are provided for members’ and guests’ convenience while using the facility. The PLAY ACTION SPORTS  DANCE & FITNESS, LLC and CAPT COMMUNITY ACTION PARADE TEAM is not responsible for vandalism, break-ins or thefts of  personal property. I understand the PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE  TEAM recommends that valuables should not be brought onto the premises. I agree to report any suspicious activity immediately to the  PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM.  REGARDING YOUR CONDUCT  • I will not bring weapons, controlled substances or alcohol on PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT.  COMMUNITY ACTION PARADE TEAM off-site premises.  • I understand that use of violence, noise, force, coercion, sexual misconduct, threats, intimidation, unsafe conduct regarding  children, fear, resistance, insults, or other conduct, intentionally or unintentionally causing disruption or preventing PLAY ACTION  SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM members’ ability to enjoy their membership or  PLAY ACTION SPORTS, DANCE & FITNESS, LLC staff’s and/or volunteer’s ability to conduct class or their job duties, is not acceptable  behavior, is in conflict with PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM  values, and may result in the termination of my membership. I am aware that the PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND  CAPT. COMMUNITY ACTION PARADE TEAM reserves the right, within its sole discretion, to withdraw membership privileges to anyone  for any reason that the PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM , in its  sole discretion, considers appropriate or in the interests of the PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT.  COMMUNITY ACTION PARADE TEAM and/or its members.  YOUR CONSENT AND RELEASE  • I HEREBY AGREE TO RELEASE AND HOLD HARMLESS PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT.  COMMUNITY ACTION PARADE TEAM, its  employees and volunteers, from any loss, liability, claim of bodily injury or property damage, or costs which may arise due to my use of the  PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM off site facilities and equipment  and my participation in PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM  programs. This agreement shall be governed by the laws of Georgia.  • I authorize the use and reproduction of any and all photographs or video footage for PLAY ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM promotional purposes without compensation, and I understand that it is the  personal responsibility of members and their guest(s) to avoid being photographed if they so desire.  • By signing this form, I agree that I have read this entire form and understand my responsibilities for participation and conduct in PLAY  ACTION SPORTS, DANCE & FITNESS, LLC AND CAPT. COMMUNITY ACTION PARADE TEAM programs and activities.  ___________________________________________________________________________________________________ Signature Name (Please Print) Date Spouse (if family membership) Date  ________________________________________________________________________________________________  Emergency Contact/Relationship Home Phone # Cell Phone #  Form updated Jan. 11, 19
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