Fill out the application form

Registration Form

J4K Spring / Summer 2012 Sessions

Student First Name

Student Last Name

DOB:

Gender: Male Female

Address:

City:

Postal Code:

Province

Home Phone #:

Cell Phone #:

Email Address:

What Club do you play for?

Game Night?

Valid Passport: Canadian Other If Other please input nationality

Health Card #:

Please list any medical conditions/concerns:

Shirt Size:

Pant Size:

Glove Size:

Select City To Register At:

Select time:

Mother's name:

Father's name:

Height:

Weight:

SAT / ACT Score:

GPA:

Academic Honors:

Showcases Attended:

Future Showcases you will attend:

Cheques Payable to : Just 4 Keepers Please note a $50.00 charge will apply to all returned cheques and cheques will no longer be accepted as payment.

Cancellation Policy: Requests for refunds must be submitted in writing prior to the first session.

$50.00 administration fee will be applied to all refunds. There will be no refunds once a program commences. In the event that another student fills the spot then a credit note minus the $50.00 administration fee will be provided to be used against the cost of future J4K programs.

Consent / Waiver Info *REQUIRED* Student’s Name: __________________________________________________ Date________________________________________

General: I authorize Just4Keepers Canada permission to take Photos and Videos of son/daughter _________________________ in training sessions when required. Pictures/videos taken may be used only for promotional purposes and for training logs.

Release/Waiver of Liability for a Minor Child: I the undersigned, individually and as parent or guardian of my son/daughter ________________________________, a minor, ask that he/she be admitted to participate in Just4Keepers Canada’s training. In consideration of such admission, I do hereby agree to release, discharge and hold harmless the directors of Just4Keepers Canada and its employees from all causes, liabilities, damages, claims or demands whatsoever on account of any injury or accident involving the said minor arising out the minor’s attendance during the program.

Medical Authorization / Release: I hereby authorize the directors and coaches of Just4Keepers Canada to provide care and medical treatment as necessary to my son/daughter ___________________________________. In the event that an illness or injury would require more extensive evaluation or treatment, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency, if I cannot be reached, I hereby give consent for emergency care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.

Privacy Policy: All personal information collected for billing, administration and J4K purposes will not be shared with, or forwarded to, a third party at any time without the permission of the client.

I the undersigned, have reviewed and understood all the above information:

Print Name of Parent/Guardian or Legal Age Student X ________________________________________________

Parent/Guardian or Legal Age Student Signature: X ____________________________________________________