Kingsway Elite Recreational Cheerleading Registration Form Player Information Last Name________________________________ First Name_________________________________ Street_____________________________ City, State___________________________ Zip Code________ Home Phone__________________________ Date of Birth_______________________ Parent Information Mother’s name____________________________ Father’s Name________________________________ Parent’s address (if different than child) _____________________________________________________ Parent’s phone # (if different than child) _____________________________________________________ Mother’s cell phone#________________________ Father’s cell phone#____________________________ Mother’s email ____________________________ Father’s email_________________________________ Medical/Emergency Contact Information Doctor’s Name_____________________________ Phone #_____________________ Primary Medical Insurance Company_____________________________ Policy #____________________ Emergency Contact______________________________ Phone #________________________________ Relationship____________________________________ ________ I HAVE RECEIVED, READ AND AGREE TO ABIDE BY THE CODE OF CONDUCT. Waiver and Release of Liability I agree to hold harmless Kingsway Elite Recreational Cheerleading, its officers, board members, coaches and sponsors for any claim arising from accidental injury to my child. We assume all the foregoing risks and accept personal responsibility for damages following such injury, permanent disability, or death. I and my legal heirs, do hereby discharge, waive and release and covenant not to sue for any and all claims of damage I may have against the above named individuals and association. The insurance policy of the Kingsway Elite Recreational Cheerleading will be secondary to any existing insurance. I understand that in my absence, emergency medical treatment may be administered to my child until such time I can be contacted. I agree to the terms and conditions of this liability release and give my permission for my child to participate in this youth activity. Parent/Guardian Signature_____________________________________ Date_______________________ *Are you interested in coaching or being a coach’s assistant? _________ Contact number______________ Initial payment due per payment schedule: 1 child $157 check #_______ 2 children $255 check #_______ 3 children $354 check #_______ **CHEERLEADERS WHO COMPETE FOR ANOTHER RECREATION ORGANIZATION CANNOT CHEER FOR KINGSWAY ELITE REC CHEERLEADING.
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