Eich’s Sports Registration Form

Head of Household Information

Last Name: ______________________ First Name: _____________________                Middle Initial: _____

Address: _________________­­­­­­­_______________________  City: __________________  Zip: __________

Daytime Phone: ( __ __ __ ) __ __ __ - __ __ __ __      Evening Phone: ( __ __ __ ) __ __ __ - __ __ __ __

Father’s Work Number/Cell: ( __ __ __ ) __ __ __ - __ __ __ __  Name of Father: ____________________  

Mother’s Work Number/Cell: ( __ __ __ ) __ __ __ - __ __ __ __ Name of Mother: ____________________ 

Emergency Number (Description of #): ______________________________________________________

Email address: ________________________________________

Program Choice

Participants Name	Sex	Birthdate	Age	Grade	Program Name	Program #	Fee

Release of Liability Waiver

Please read this form carefully and be aware that in signing up and participating in this program/activity, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with this program/activity. _____ Initial

I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity and I voluntarily agree to assume the full risk of any and all injuries, damages or loss regardless of severity, that my minor child/ward or I my sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my minor child/ward) as a result of participating in this program/activity against Eich’s Sports owners, including its officials, agents, volunteers, contractors and employees (hereinafter collectively referred to as “Eich’s Sports”). _____ Initial

I do hereby fully release and discharge the Eich’s Sports from any and all claims for injuries, damages or loss sustained by anyone arising out of, connected with, or in any way associated with this program/activity. _____ Initial

I understand the nature of this program and have read and fully understand the above important information, warning of risk, assumption of risk and waiver release of all claims. _____ Initial

Permission To Photograph And Videotape Participants Is Authorized By Your Signature On This Waiver.

By signing this waiver, I understand that my child/ward or I may be photographed or videotaped at any Eich’s Sports program, event, or facility. I give permission for photographs and videotapes of my child/ward or me to be used to promote Eich’s Sports through press releases, brochures, the web site, and other promotional materials. Such photographs and videotapes will remain the property of the Eich’s Sports. Please tell the instructor and photographer if you do not want to be photographed. _____ Initial

Participant’s Signature Required (A parent/guardian must sign if participant is under age 18):

________________________________________________________________________ Date: _________

Signature                                                          Print Name

 

Credit/Debit Card Information    Fax (815)436-3686 or email briane@eichssports.com

o Visa o Master Card    Card #: __ __ __ __   __ __ __ __   __ __ __ __   __ __ __ __  Code #: _____

Exp. Date: __ __ / __ __ __ __             Payment Amount: $ __ , __ __ __ . __ __

Name (Please Print):_______________________________________________

Signature: ______________________________________   Date:  _______________

I agree to pay the above amount according to card issuer agreement.

Name of participant: ________________________