Fall Registration

Which program are you registering for? *

What school does the participant attend? *

Participant's name *

First

Last

Participant's date of birth *

What grade is the participant in? *

Parent/Guardian's name *

First

Last

Parent/Guardian's email address *

Parent/Guardian's contact number *

Parent/Guardian's Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of emergency contact *

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Last

Emergency contact's phone number *

Relationship to participant *

Any other health issues or prescription drugs?
(if yes, please describe) *

Please check the following to confirm you agree.

Purpose of the program: The purpose of the program is to empower your daughter with self- confidence, increase your daughter’s activity/fitness level and self-esteem while at the same time teaching life skills that will be beneficial to her as she enters adolescence. *

Yes

Pre- and Post Session Evaluation: With your permission, your daughter may complete a confidential pre and post survey at the beginning of the program and at its end. The survey measures student attitudes towards school, family, self and peers. The purpose of this survey is to measure any group attitudinal changes that may (or may not) occur because of participation in this program. You are asked to get involved in your daughter’s experiences, please advise Ashley (facilitator) if there are any changes in your daughter’s behavior during the program. *

Yes

Release (Injuries): Serious health risks are rare. Physical reactions to exercise may include heat related illnesses, abnormal heartbeats and blood pressure and in rare instances heart attacks. While we take all reasonable precautions, we can make no guarantees regarding these risks. You (the parent or legal guardian) agree not to hold Ashley Wiles or Sole Girls liable for any injury or damages due to participation in the Sole Girls program. *

Yes

Release (Photo): During the program, we occasionally take photos and videos of the girls for use in our future programs and to recap the event for the girls at the end of the program. With your permission given herein, we may also use these photos and videos for future brochures, publications, or in other ways to promote the program. *

Yes

Authorization: I,the parent, have read this form and I am aware that by signing it I am waiving certain legal rights. I understand there are inherent risks associated with physical activity. To the best of my knowledge there are no contradictions to my daughter’s participation in the Sole Girls program. By my signature below, I give permission for my daughter to participate in this program, including the evaluation testing, for any pictures or videos in while she appears to be used as described above and for the information specified above. Cancelation Policy: 2 weeks prior to the beginning of the course 10% fee is charged. Less than 2 weeks prior to the course a 20% fee is charged. No refund will be issued once the course has begun. *

Yes

I, AGREE TO THE ABOVE TERMS BY TYPING MY NAME BELOW *

First

Last

Signed, Today's Date *

Fall Program Registration Form