Simply Sports -- registration form

REGISTRATION FORM

Class Title: _________________________________________________________
Day & Time: _________________________________________________________
Child's Full Name: _____________________________________________________________
Grade: ______________ Male [ ] Female [ ]
Home Telephone: _________________________ Birth Date: ___________________________
School: ______________________________________________________________________
Home Address: ________________________________________________________________
Zip Code: __________
Parent #1: ___________________________________________________________________
Bus. Phone: ____________________________ Cell Phone: ____________________________
E-Mail: __________________________________________________
Parent #2: ___________________________________________________________________
Bus. Phone: ____________________________ Cell Phone: ____________________________
E-Mail: __________________________________________________
Emergency Contact (other than parents): ______________________________________________
Emergency Contact Phone: _________________________________________________
List any Allergies or other special concerns: ____________________________________________
Please Refer a Friend: Name of Child: ______________________________________________
Grade: _________________ School: __________________________________________
Email: ___________________________________________
Address: ________________________________________________________________________
For League Games: Height: ____________ Shirt Size: ____________ Short Size: ______________
You may request ONE friend for your child's team but we do not make any guarantees and requests must be received in writing by both parties to be eligible for consideration: ______________________________________

Payment: Payment Amount $ ______________________ [ ] Visa [ ] MasterCard [ ] Check payable to Simply Sports
If paying by check, mail your completed forms and check to Simply Sports, 370 East 76 Street, Suite B1403, New York, NY 10021. If paying by credit card, fax your completed forms to (212) 879-4069.
Visa or MC Credit Card # _______________________________________________ (No American Express)
Exp. Date: ____________________ CVS Security Code: ______________
Name on Card: ______________________________________________________
Billing Address (check here [ ] if billing address is same as home address) If different:
______________________________________________________
______________________________________________________
______________________________________________________
Contact Information: For more information, please contact Jeffrey Bernstein at jeff@simplysports.net or call us at (877) 213-2255 or (917) 816-6828. Fax form to (212) 879-4069.
Permission for Participation. My child is permitted to fully participate in the voluntary, recreational, athletic and extra-curricular activities sponsored by Simply Sports (the "Program").
Permission for Transportation. I permit my child to be transported to and from the Program in any manner, including transportation by car or 15 passenger van driven by an employee of Simply Sports.
Release from Liability. In consideration of permission to use, today and on all future dates, the property, facilities, staff, equipment and services of Simply Sports, I, for myself, my children, spouse, heirs, agents, personal representatives and assigns, hereby release, waive and forever discharge Simply Sports, its directors, officers, employees and agents, from liability from any and all claims, demands, damages, actions and causes of action, pertaining to or arising out of my child's participation in the Program, including but not limited to, claims for negligence resulting in personal injury, accidents or illnesses (including death), breach of contract, or breach of warranty arising from participation in activities, classes, observation and use of facilities, premises or equipment and transportation to or from a Program.
Covenant Not To Sue: I understand that, as a result of my executing this release, I am forever barred from suing Simply Sports, its officers and its employees, as a result of my child's participation in the Program.
Assumption of Risks: Physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Simply Sports uses facilities for and provides for activities such as running ad sporting activities. Some of these involve strenuous exertions of strength using various muscle groups, some involve quick movements involving speed and change of direction, and others involve sustained physical activity which places stress on the cardiovascular system. The specific risks vary from one activity to another, but the risks range from minor injuries such as scratches, bruises and sprains, to major or catastrophic injuries such as eye injury or loss of sight, joint or back injuries, concussions, heart attacks, paralysis and death. I have read the previous paragraphs and I know and understand and appreciate these ad other risks that are inherent in the Program. I hereby assert that my child's participation is voluntary and I knowingly assume all risks. I acknowledge that my child must strictly adhere to all rules and instructions during the Program. To the best of my knowledge, my child is in good health and has no disability or condition that renders his/her participation in the Program medically inadvisable, or otherwise limits his/her ability to participate. In an emergency, Simply Sports or its designees will attempt to reach me (my emergency contact) as soon as possible but I understand that Simply Sports will use its best judgment should it not be possible to contact me. I permit any physician selected by Simply Sports or its designee to hospitalize, secure treatment for and to order injections, anesthesia or surgery for my child. I also permit Simply Sports or its designees to transport my child to the hospital or medical/dental office if needed.
Photo Release. I give my consent to the use of photographs taken of me or my children by Simply Sports, or its agents, to be used for editorial or promotional uses only and waive all rights to compensation and other rights which may arise as a result.
Authorization: BY SIGNING AND DATING BELOW, I ACKNOWLEDGE I HAVE READ AND I ACCEPT ALL ENROLLMENT CONDITIONS AND POLICIES STATED ABOVE AND AS SET FORTH ON WWW.SIMPLYSPORTS.NET, INCLUDING THE RELEASE FROM LIABILITY AND REFUND POLICY AND THAT I AM SIGNING FREELY AND VOLUNTARILY AND INTENT BY MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. I understand that if any portion of this Agreement is deemed to be ineffective, the remaining provisions shall continue to be effective.
Child's Name: __________________________________________________________________
Parent/Guardian Print Name: ______________________________________________________
Relationship: ____________________________________________________________________
Signature: ______________________________________________________________________
Date: ____________________________
Duration of Authorization: (CHECK HERE [ ] if you direct Simply Sports to keep your authorization on file for all programs that your child participates in during the next 12 months). IF YOU CHECK THIS BOX, ALL TERMS OF THIS AUTHORIZATION, INCLUDING THE RELEASE FROM LIABILITY, REMAIN IN FULL FORCE AND EFFECT FOR ALL ACTIVITIES IN WHICH YOU CHILD PARTICIPATES.