Registration Form

Keiki Klub Registration Form

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Thank you for your response. ✨

I am registering for the following kK programs: (required)

My Keiki participated in a kK program between September 2019 – April 2020(required)

Yes *No

Keiki First Name

Keiki Last Name

School

Street Address

City, State and ZIP

Parent/Guardian First and Last Name (1)

Telephone 1

Email 1

Parent/Guardian First and Last Name (2)

Telephone 2

Email 2

Emergency Contact Name

Emergency Contact Number

Hospital of Choice

List of Allergies

If answered “Referral-Friend”, who referred you?

Waivers and Release

PARENT/GUARDIAN WAIVER FOR MINORS The Undersigned parent and/or natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward’s participation in the Event, and has agreed individually and on behalf of the child or ward, to the terms of the Agreement, Waiver and Release of Liability set forth above on behalf of the minor and the parents or legal guardian.

WAIVER AND RELEASE OF LIABILITY AND INDEMNITY AGREEMENT Keiki Klub Sports, INC. “Clinic” Upon signing this Agreement and forever thereafter, you agree that if you participate in or attend any Clinic or Clinic related event, or that of any Clinic team (“Team”), or are present on Clinic or Team premises or use any Clinic or Team facility, you do so at your own risk and assume the risk of any and all injury and/or damage you might sustain, regardless of whether you are a participant, a spectator, or otherwise. Your assumption of risk includes but is not limited to the use of any sports or other equipment (mechanical or otherwise), and accessing Clinic or Team premises. You further agree to assume the risk of your participation in or presence at any sporting event, practice, activity, class, program, instruction, or Clinic or Team sponsored event. You agree that you are voluntarily participating in the aforementioned activities and assume all risk, known and unknown, associated with same. You agree on behalf of yourself (and your spouse, all your children, personal representatives, heirs, executors, administrators, agents, and assigns) to forever release and discharge Clinic and Team, their owners, employees, agents, representatives, affiliates, successors, and assigns from any and all claims or causes of action (known or unknown) arising out of the negligence of Clinic or Team, whether active or passive, or that of any of its affiliates, employees, agents, representatives, successors, and assigns. This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any equipment or facilities which may malfunction or break, (b) Clinic’s or Team’s improper maintenance of any exercise equipment or facilities, (c) Clinic’s or Team’s negligent instruction or supervision, including personal training, strength training, refereeing and coaching,(d) you slipping or tripping and falling while on Clinic or Team premises, including Clinic’s or Team’s negligent inspection or maintenance of such premises, and (e) you sustaining personal injuries as a result of the dangerous condition of property on which you are present in relation to any Clinic or Team function, including Clinic’s or Team’s negligent inspection or maintenance of such premises. By executing this Agreement, you hereby agree to indemnify and hold harmless Clinic and Team from any loss, liability, damage, or cost Clinic or Team may incur due to your presence at any Clinic or Team premises or facility. You further expressly agree that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the law of the state in which this agreement is entered into, and that if any portion of this agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release is not intended as an attempted release of claims of gross negligence or intentional acts. You acknowledge that Clinic and Team provide a service to their members and is not in the business of selling, leasing, or otherwise placing into the stream of commerce exercise or sports equipment, or other such products, and the use of any such items is incidental to the service provided by Clinic and Team. YOU ACKNOWLEDGE THAT YOU HAVE CAREFULLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY, AND EXPRESS ASSUMPTION OF RISK AND INDEMNITY AGREEMENT. YOU ARE AWARE AND AGREE THAT BY EXECUTING THIS WAIVER AND RELEASE, YOU ARE GIVING UP YOUR RIGHT TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST LEAGUE OR TEAM FOR THEIR NEGLIGENCE, OR FOR ANY DEFECTIVE PRODUCT ON THEIR PREMISES. YOU HAVE READ AND VOLUNTARILY SIGNED THE WAIVER AND RELEASE AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS, OR INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAS BEEN MADE. YOU AGREE, FOR YOURSELF AND YOUR SPOUSE, CHILDREN, SUCCESSORS, HEIRS AND ASSIGNS, THAT THE ABOVE REPRESENTATIONS ARE CONTRACTUALLY BINDING, AND ARE NOT MERE RECITALS, AND THAT SHOULD YOU OR YOUR SUCCESSORS ASSERT ANY CLAIM IN CONTRAVENTION OF THIS AGREEMENT, THE ASSERTING PARTY SHALL BE LIABLE FOR THE EXPENSES (INCLUDING REASONABLE ATTORNEYS FEES) INCURRED BY THE OTHER PARTY OR PARTIES IN DEFENDING AGAINST ANY SUCH ACTION.

By checking this box, I agree to the above statement and the terms mentioned in the Waiver and Release of Liability and Indemnity Agreement.

PHOTO AND MEDIA RELEASE I hereby grant permission for digital photographs to be taken of my child as part of his/her participation in the Keiki Klub program. I authorize Keiki Klub to use my child’s image on its website, social media page and/or printed in promotional materials without further consideration and I acknowledge Keiki Klub’s right to treat the media (such as cropping) as its discretion. NOTE: Names of athletes will NOT be identified. I also acknowledge that Keiki Klub may choose not to use my child’s image at this time, but may do so at its own discretion at a later date. By signing this release form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person affiliated with Keiki Klub utilizing this material for marketing and promotional purposes.

Payment

Checks should be made to: KEIKI KLUB SPORTS INC. Subject: Child’s First & Last Name KEIKI KLUB 19 Blantyre Circle Thornton PA 19373 *Registration is pending for 2 weeks until full payment is received.* **You will receive a confirmation email within 7 days of receiving your check. Checks will be deposited near the start date of your child’s session. I understand that my registration is pending until KK receives my full payment. Payment should be post-marked within 2 weeks of registration. My child’s spot will no longer be available if payment is not received within 2 weeks of registration date.

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