Kidokinetics Registration Form

Child First Name *

Child Last Name *

Date of Birth *

Gender *

---MaleFemale

Parent/Guardian First Name *

Parent/Guardian Last Name *

Phone *

Cell Phone *

Emergency Contact Relation

Address 1

Address 2

City

State/Province

Zip

Country

Primary Physician

Primary Physician Phone

Health Insurance Company

Photo Release

Pictures of your child participating in our fun classes may be included on the Kidokinetics.com website or other advertising materials. The child’s name will not be disclosed. Please indicate below whether your child’s pictures may be used by Kidokinetics. All photographs are the sole property of Kidokinetics Dallas.

 

By signing below and clicking “authorize” below, I hereby grant permission for Kidokinetics Dallas to use any pictures or photographs of my child on the Kidokinetics.com website, or other advertising materials including, brochures, pamphlets, or newspaper articles. I also acknowledge that these pictures / photographs are the property of Kidokinetics Dallas and that no royalties or payments are due in connection with their use.

 

Authorization: *

• I AUTHORIZE
• I DO NOT AUTHORIZE

Responsibility for Payment/Release

The undersigned agrees to be responsible for and to pay Kidokinetics Dallas or the sponsored facility for any billed charges associated with the participation of the child listed above in the Kidokinetics program. The undersigned, on his or her own behalf and on behalf of the child listed above, hereby releases Kidokinetics Dallas from any and all liability arising out of or connection with the above listed child’s participation in any Kidokinetics Dallas program and further waive any and all claims of any kind against Kidokinetics Dallas, its officers, agents or employees. Kidokinetics Dallas accepts checks, Visa and MasterCard for program charges.

Parent/Guardian Type Full Name

By typing your name in the signature box and clicking submit, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions.