Request edit access
Registration Form
Payment is not required now. 

Please be advise that there is no registration fee, no payment in advance. We understand that some of the children are young and the class might not be suitable for their age yet, but if you start the class payment of 60₪ will be required. Our coaches commit to the class based on the amount of children.

Sign in to Google to save your progress. Learn more
Email *
Name of your child *
Date of Birth:
MM
/
DD
/
YYYY
How old is you child? *
Required
Chose location  *
Required
Allergies/Medical conditions or other concerns : *
Required
If the answer to the above is yes please explain:
Parent/Guardian( Name): *
Phone #: *
How did you hear about us ?
       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.



*
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report