Girls' Ultimate Movement Clinic Registration: Lenexa, Kansas
Register your child for the GUM clinic here!

Remember to print and bring the Medical Authorization form to the clinic,
http://www.usaultimate.org/assets/1/Page/Medical%20Authorization-V4.1.form.pdf.

You will have a chance to consent to the USA Ultimate Waiver at the end of this registration form, https://www.usaultimate.org/assets/1/Page/2018%20USAU%20Waiver.pdf. This means you won't need to complete this form at registration or bring the completed USA Ultimate Waiver to registration.

What is the clinic participant's first and last name? *
Your answer
What is the participant's date of birth? *
Your answer
What is the participant's gender? *
What is the participant's street address? *
Your answer
What is the participant's city, state and zip code? *
Your answer
What is the participant's approximate projected high school graduation date (month/year)? *
Your answer
What is the name of the school the clinic participant attends? *
Your answer
What is the parent or guardian's first and last name? *
Your answer
What is the parent or guardian's email address? *
Your answer
What is the parent or guardian's phone number? *
Your answer
What is the clinic participant's experience with ultimate? *
How did you hear about this Learn to Play Clinic? *
Please check all that apply.
Required
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to indemnify and hold harmless the releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs above, even if arising from their negligence, to the fullest extent permitted by law. *
By clicking 'Yes' below you are consenting to the USA Ultimate waiver. This means you won't need to complete this form at registration or bring the completed USA Ultimate Waiver to registration. You do still need to have the participant bring the completed USA Ultimate Medical Authorization form to the clinic. A copy of this is listed at the end of registration.
Required
View USA Ultimate waiver by clicking on the below link.
Remember to print and bring the USA Ultimate Medical Authorization form to the clinic.
USA Ultimate Medical Authorization Form
Please make sure to bring this completed form to the clinic.
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