Winter Break Registration Groupon / Living Social Number:If you purchased camp on Groupon or Living Social please provide the 8 digit Groupon Voucher or the Living social number below.Child's Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender*MaleFemaleBirthday*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade*Parents Name* First Last Phone*Email* EMERGENCY INFORMATION:Name*EMERGENCY CONTACT 1 Phone*Name*EMERGENCY CONTACT 2 Phone*CHILD RELEASE AUTHORIZATION:Name & Relationship*Phone*Name & Relationship*Phone*Name & Relationship*Phone*INFORMATION REQUIRED BY STATE LAW:Health Insurance Company*Policy Number*Family Physician*Phone*DOES YOUR CHILD HAVE ANY ALLERGIES?Please select:* Yes No Hay Fever* Yes No Poison Oak/Ivy* Yes No Bee Sting* Yes No Penicillin* Yes No Food Allergies* Yes No If "Yes" Please list food allergies:*I authorize KidSportz USA staff to apply sunscreen to my child's exposed skin.* Yes PLEASE SIGN OUR TERMS OF AGREEMENT BELOW:I am over the age of 18 and wish to enroll my child in Kidsportz USA Programs at Med-X Sports & Fitness Ctr. I agree that Kidsportz USA and Med-X Sports & Fitness Ctr. is not responsible for any accidents that happen to my child while in the Kidsportz USA program. I understand that the Kidsportz USA training programs are not medically supervised programs and that these programs were developed for healthy people with no medical conditions or risks (physical or psychological). If my child has an existing medical condition, I will present my coach with a physicians release form, signed and dated by their personal physician. This form represents my physicians approval to participate in the Kidsportz USA training program. I understand that this form must be submitted before you can officially enroll your child. I grant permission to my coach to contact my physician or healthcare professional if I require medical supervision during my child's participation in the training program. **ALL SALES ARE FINAL NO REFUNDS. **PARENTS MUST PICK UP CHILD(REN) NO LATER THAN 5 MINUTES AFTER THE END OF CLASS. FAILURE TO DO SO WILL RESULT IN A $20/DAY FEE. **THERE IS A ONE-TIME ENROLLMENT OF $49 PER CHILDAgree to Terms and Conditions* Click here to agree to the Terms and Conditions above. Please Sign & Agree Below:*EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.