KEEN's Athlete Registration Form
Parents: Please take your time in filling out this form. Be as detailed as possible and add additional pages as needed. Please offer specific suggestions as to how KEEN volunteers can be most effective in coaching your child.
Applicant's Information
Athlete's First Name *
Your answer
Athlete's Last Name *
Your answer
Gender *
Date of Birth (MM-DD-YYYY) *
Your answer
Age *
Your answer
Home Address
Street *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Home Phone Number (0000000000) *
Your answer
Emergency Cell Phone (0000000000) *
Your answer
School
Your answer
Siblings
Your answer
Parent's Information 1
First Name *
Your answer
Last Name *
Your answer
Parent Relation *
Home Phone Number (0000000000) *
Your answer
Cell Phone Number (0000000000) *
Your answer
Email Address *
Your answer
Employer Name
Your answer
Work Phone Number (0000000000)
Your answer
Parent's Information 2 (optional)
First Name
Your answer
Last Name
Your answer
Cell Phone Number (0000000000)
Your answer
Email Address
Your answer
Employer Name
Your answer
Work Phone Number (0000000000)
Your answer
Special Skills that parents could offer to KEEN
Special Skills
For example: graphic designer, programmer, web-based skills etc...
Your answer
Other Emergency Contacts
Name and Phone Number *
Your answer
Athlete's Profile
Disability: *
Your answer
Ability: *
Your answer
Physical Limitations: *
Your answer
Strengths: *
Your answer
Weaknesses: *
Your answer
Behavior Problems/Issues *
Your answer
Left-or Right-Handed *
Your answer
Communication *
Your answer
Toileting Skills: *
Your answer
Other:
Your answer
Helpful Hints/Suggestions For Coaching My Child *
Calming techniques, methods for motivating, etc...
Your answer
Medical Conditions/Needs
Medications, specific procedures you wish to be followed in the event of a seizure, injury, or other health-related incident that might occur at a KEEN activity
Your answer
Child's Favorite Activities:
Your answer
What you hope your child will gain from KEEN
Personal goals, sports skills, socialization, etc...
Your answer
Target Areas
Long terms goals such as practice catching a ball with both hands etc...
Your answer
Liability and Publicity Release and Waiver
Liability Release *
In consideration of the opportunity to participate in events or activities that are organized or coordinated by Kids Enjoy Exercise Now USA or one of its subsidiaries or Affiliates (“KEEN”), including sports and recreational activities (each, an “Event”):I, the undersigned, on behalf of myself and/or my children for whom I am the parent or legal guardian authorized to act on their behalf (collectively “Children” and each a “Child”) (together, me and them, the “Participants”), and on behalf of my and my Children's heirs, estates, insurers and assigns, agree that KEEN and its Affiliates shall not be responsible or liable for, and irrevocably release and discharge KEEN and its Affiliates, and their officers, directors, employees, agents and volunteers, from any claims or liability of any kind arising from any losses, damages or injuries (including death) to persons or property of any kind resulting, in whole or in part, directly or indirectly, from attendance at or participation in any Event, including without limitation, during travel or transportation to or from an Event whether by transportation provided by KEEN or its Affiliates or any other means. This indemnity and obligation to defend and hold harmless shall survive any termination of this Release or the parties' activities hereunder.
Required
Emergency Release *
If a child becomes sick or injured during a KEEN session, the parent and/or emergency contact will immediately be contacted. EMT’s may also be contacted. If I or my designated emergency contact cannot be reached, I do hereby consent to any necessary emergency treatment that an attending physician may order, and understand that no necessary treatment will be withheld. I will keep KEEN informed of medications and/or allergies my child has, as required by this application. I agree to indemnify and hold harmless KEEN (including its officers, directors, members and/or volunteers) from any claim on account of such treatment, and will assume full responsibility for any such action, including payment of associated costs.
Required
Publicity Release *
I do hereby consent, agree and give permission to KEEN, and their officers, directors, employees, agents and volunteers, to take photographs and make videotape, audiotape, or digital recording of the participants at the event and to use, reproduce, exhibit, publish and otherwise exploit the participants' likenesses, names, voices, statements, personal stories and biographies (collectively, "likeness), alone or with others, in any and all media, now or hereafter known, throughout the world in perpetuity for promotional, publicity, training and similar purposes. The likeness may be altered or modified in KEEN's and/or its affiliates' sole discretion. I waive any opportunity or right to inspect or approve any such use or exploitation of the likeness on behalf of the participants. I agree that all materials created by or for KEEN and/or its affiliates are the sole property of KEEN and its affiliates all right, title and interest, including copyright, in such matter in any and all media, now or hereafter known, throughout the world in perpetuity.1. I, on behalf of the Participants and on behalf of my and my Children's heirs, estates, insurers and assigns, irrevocably release and discharge KEEN and its Affiliates, and their officers, directors, employees, agents and volunteers, from any claims or liability of any kind arising from the making, use, reproduction, publication, marketing or other exploitation of the Likeness, and any alteration or compilation thereof. I waive any rights, claims, or interest that the Participants may have to control the use of the Likeness in any manner or in whatever media used. I understand that there will be no financial or other remuneration to the Participants for creating or exploiting the Likeness.2. Regarding the releases granted herein, I expressly waive California Civil Code § 1542, or any other statute of similar import or effect, that otherwise may exclude unknown claims from this release. I acknowledge that I am familiar with the provisions of California Civil Code § 1542, which provides as follows: “A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR.” Being aware of said code section, I hereby expressly waive any rights I may have thereunder, as well as any other statute or common law principles of similar effect.3. I, on behalf of the Participants, and on behalf of my and my Children's heirs, estates, insurers and assigns, will indemnify and hold harmless KEEN and its Affiliates, and their officers, directors, employees, agents and volunteers, from and against any losses, actions, claims, damages, or expenses of any kind, including without limitation attorneys' fees and costs, which may be incurred by or asserted against or by any of them, by any Participant or any third party, arising from or relating to (i) the making, use, publication, marketing or other exploitation of the Likeness in any manner whatsoever. This indemnity and obligation to defend and hold harmless shall survive any termination of this Release or the parties' activities hereunder.
Required
Summary Authorization
I represent that I am the parent or legal guardian authorized to act on behalf of the Child applicant and any other siblings or Children I may have with the right to grant all of the consents, releases, waivers and indemnities granted herein on their behalf , or that I am over 18 years of age and have no legal guardian.

*I have read and understand the above representation concerning the KEEN Liability Release, Emergency Release, and Publicity Release. My click in the box by the agreement and below signifies my agreement on behalf of my Child, myself, and any siblings or children I may have to (1) the terms of the Liability Release, (2), the Emergency Release, and Release and(3) the Publicity Release.
Name *
Your answer
Address *
Your answer
Relationship to applicant *
Your answer
I am age over 18 *
Date *
MM
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DD
/
YYYY
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