Play For Sport

Enrollment for Play For Sport Classes at Fieldhouse USA Sports Facility Only!

Child 1
Name: First,
Last

Current Age:

Birthday

	Male

	Female

Child 2
Name: First,
Last

Current Age:

Birthday

Male

	Female

Child 3
Name: First,
Last

Current Age:

Birthday

Male

	Female

CLASS(ES)
to be
Enrolled
In:
(check all
that apply)

Mother's
Name:

Home Number:

Street
Address:

City, State, Zip

Home
Phone:

Work/Cell
Phone:

Primary
Email
Address:

Secondary
Email:

Father's
Name:

Home Number:

Street
Address:

City, State, Zip

Home
Phone:

Work/Cell
Phone:

Primary
Email
Address:

Secondary
Email:

Consent for
Media
Usage:

Occasionally,Play For Staff, Inc. staff may photograph students with the intent of using the pictures in various
publications and/or on our web site (www.playforsport.com). Similarly, Play For Sport, Inc. may wish to promote our
student's accomplishments by sending press releases to appropriate newspapers or publications. In addition,
representatives of the media may be interested in stories relating to Play For Sport, Inc.and may wish to interview,
photograph or videotape our students. Please complete this form below. Non-response to this request will indicate
that you grant permission as indicated below.

I HEREBY:			Permission for press releases to be distributed about my son/daughter, and for photographs of and/or interviews with my child to appear in other mediums for as long as my child(ren) is enrolled in Play For Sport, Inc.
	Grant


		Do Not Grant

Physical
Limitations:

Play For Sport, Inc. is a physically active program. Please list and describe below any injuries, allergies, or health
conditions which might limit your child’s participation.

Parental
Consent:

I understand all fees are due in advance and that they are due regardless of absences. Any missed classes must be
made up within 30 days. AND I, the minor's parent and/or legal guardian, understand the nature of the above
referenced activities and the Minor's experience and capabilities and believe the minor to be qualified to participate in
such activity. I HEREBY release and hold harmless Play For Sport, Inc. and all its employees in the event of accidents
and/or injuries that are caused or alleged to have been caused by my child's participation.

		I accept and agree to the terms outlined above and certify that all information provided on this enrollment form is true and correct as of the date the enrollment form was submitted.