Step It Up Tutoring and More, LLC

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Physical Education Class Registration 2022-2023

**Payment will be collected 1st day of class**

Child's LAST Name *

Child's FIRST Name

Child's Age *

Birthday *

YYYY

Parent or Guardian's LAST name *

Parent or Guardian's FIRST name *

Phone Contact *

Email address *

Home address

(STREET ADDRESS, CITY, ST, ZIP)

Health Concerns or Medication

Include any health or other information that you feel I need to know about your child. (Is your child on medications which may affect their balance, coordination, breathing, or heart rate). Please list all medications that could affect their participation in class.

Does your child have allergies? If so, what? *

1st Emergency Contact *

1st Emergency contact phone number *

2nd Emergency Contact --Other than Parent RELATIONSHIP *

2nd Emergency contact phone number *

Doctor and phone number *

Hospital *

Release Statement, the parent or legal guardian for the participant child, hereby give my consent and agree to release and indemnify and hold harmless Step It Up Tutoring and More, LLC and any and all instructors conducting practices/activities, from all damages for any claim arising out of any injury, physical or mental, to or loss of life by any participant, in any way related to any participants presence at or participation in Step It Up Tutoring and More, LLC facilities or activities, including, without limitation any complications to such injuries caused/aggravated by any participants pre-injury state of health or refusal to obtain medical treatment based on any personal beliefs or otherwise. Furthermore, I hereby authorize personnel associated with Step It Up Tutoring and More, LLC, as my agents, to take actions, to consent to medical/surgical exams/treatment as may be required in emergencies to preserve the physical well-being of any participant; provided prudent efforts have been made to contact any legal guardian to notify the same of the situation. If there is any dispute about this release I agree to participate in mediation or arbitration. *

**Due to the fact that I cannot confirm the identity of the person completing this Registration Form, a signature will be required on a provided copy of this Release Statement Form on the first day of class at Step It Up Tutoring and More, LLC. Please type your initials that you understand the above statement.

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