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Registration Form
Email address *
Name of your child *
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Date of Birth: *
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How old is you child? *
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Chose location *
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Allergies/Medical conditions or other concerns : *
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Can your child receive candy ? *
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Parent/Guardian: *
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Mailing adres: *
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Phone #: *
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Waiver and Release
Agreement to Participate in JaxKickStars

I agree to have my child participate in a physical activity at JaxKick Stars, I affirm that my child’s general health is good and that he/she is not adversely affected by exercise. I am aware of the possibility of accidental or other physical injury during exercise programs. In consideration of participating at the JaxKick Stars, I do hereby agree to assume all risks of such injury and will hold harmless from any and all liability, actions, causes of action, claims and demands of every kind and nature whatsoever which I now have or which may arise of or in connection with any participation in activities arranged by jaxKick Stars, its employees and staff. The terms herein shall serve as a release and assumption of risk for my heirs, executors and administrators for all members of my family, including any minors.I further understand that in the event of a medical emergency, JaxKick Stars will call EMS to render assistance and that I will be financially responsible for any expenses involved. I do hereby consent and agree that JaxKick Stars has the right to take photographs and video of my child during JaxKick Stars sessions. These photos and video may be used on the company website (www.jaxkickstars.com), company Facebook pages, and promotional material without compensation. I understand that my child’s name and identity will not be revealed. If you would prefer we not take photographs or video your child, please notify us via e-mail. I have read the above statement and have agreed to the conditions stated therein and agree to abide by all JaxKick Stars policies and rules of conduct.

Policies and Procedures
Whenever possible, we will use indoor space during inclement weather. If there is no indoor space available, there will be a maximum of two make-up weeks due to inclement weather (extreme cold, heat or rain)

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Payment
Credit card payment http://www.jaxkickstars.com/payment.html

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PayPal link below.​ Select the number of children you would like to register.

https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=WUYL3LW3UQQ4G

A copy of your responses will be emailed to the address you provided.
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