Next Level Summer Break 2023

Athlete Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• Prefix: --Choose-- Mr Mrs Miss Ms Dr Prof Rev Fr Sr Rabbi
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Cell Phone:
• * Age
• * Birthdate
• * Phone:
• *

  Gender

  • Male
  • Female

Parent Information

• * Name
• * Phone Number
• * Email
• * Emergency Contact Name/Phone
• *

  Does your child have any medical limitations? If yes, please describe.

  • Yes
  • No
• If yes, please describe:
• * Physician Name & Contact Info:

• Liability Release and Media Release Agreement: I, the parent and/or legal guardian of the above named minor child/ward/participant hereby give my approval to said minor's participation and do forever release, acquit, discharge and covenant to hold harmless Spike and Serve Club and all of its representatives, coaches, volunteers, assistants, Kevin Wong and Sherry Wong from any and all liability and from any and all actions, causes of action and claims for any injury or damage and any and all liability for any such injury or damage including covid19 or any/all potential virus. I hereby authorize the personnel of Spike and Serve Club to take any necessary steps for the required medical treatment for said minor participant. I hereby release Spike and Serve Club from any and all liability for any medical treatment decisions made for the treatment of said child/ward. I consent to have my child's likeness, photograph or video used for all Spike and Serve media purposes.

• *

  I agree to the above Liability & Media Release Agreement. If "no" is chosen, I understand that my child may not participate in this Spike and Serve Club program.

  • Yes
  • No

Sibling Information

You may add a maximum of 1