Speed and Agility Camp Registration

First Name*

Last Name*

Parent/Guardian First and Last Name*

Sex*

Male

Female

Date of Birth*

Fall 2019 Grade Level*

Street Address 1*

Street Address 2

Town / City*

State / Province*

Postcode / Zip*

Home Phone

Mobile Phone*

Email*

Emergency Contact Name*

Emergency Contact Number*

Password*

Confirm Password*

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<h3>Health History</h3>

Please check each health history item if the individual participating the camp has experienced these symptoms. Explain all checked boxes in the space provided below.

<H3>Family History</h3>

Please check each family history item if the individual participating in the camp has experienced these symptoms. Explain all checked boxes in the space provided below.

Checkbox Group*

Any relative ever have a sudden unexplained death (less than 50 years old)

Any immediate family member have high cholesterol

None or not applicable

Please explain all yes or checked boxes/answers here. Age at time of injury should be included.

<h3>Medications (Inhalers/Epi-Pens)</H3>

Please type any medications currently prescribed by a health care professional or recently prescribed

Parent/Guardian/Responsible Party*

Today's Date*

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<h3>Consent</h3>

I acknowledge that, by signing this document, I have voluntarily chosen to participate in a program of progressive physical exercise that can enhance the musculoskeletal and cardiorespiratory systems. In signing this document, I acknowledge being informed of the possible strenuous nature of the program and the potential for unusual, but possible physiological results including, but not limited to, abnormal blood pressure, fainting, heart attack or death. By signing this document, I assume all risk for my health and any resultant injury or mishap that may affect my well-being. I also agree to hold harmless of any responsibility, the instructor, facility or any persons involved with this program and testing procedures. I understand that questions about exercise procedures and recommendations are encouraged and welcomed.

Parent/Guardian/Responsible Party (By typing your name you agree to the terms above)*

<h3>Financial Policy</h3>

Group Classes/Camps:

I understand that payment for wellness programs is expected in advance. No refunds or credits will be given for missed or cancelled sessions.

Parent/Guardian/Responsible Party (By typing your name you agree to the terms above)*

<h3>Photo Release</h3>

I hereby give Integrated Rehabilitation Services (IRS) consent to photograph me and to edit, copy, display, distribute or publish these photos for the purposes of promoting their services in the community. I understand that any photo used will become the property of Integrated Rehabilitation Services. I also release all rights to photos for future promotion.

Photo Release Consent*

Yes

Parent/Guardian/Responsible Party (If you have selected 'Yes' to the Photo Release, by typing your name you agree to the terms above)

Today's Date*

Speed and Agility Camp Registration

Payment Details

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