PLYOCITY Registration Form

CBC LACROSSE

 

Participant’s Last Name, First Name

______________________________________________________

Age:  ___ DOB: _______ Height: _____ Weight: _____

Home Address_________________________

City, State, Zip_______________________________________________________

Parent/Guardian: _______________

Parent’s Email_______________________@_________

Home Telephone, Emergency Telephone ____________/____________

Any Health Issues / Injury History (if none please state “none”):                                                                   ____________________________________________________________

 

PROGRAM(S) SELECTED

PROGRAM

Fee

Fee Due

*(  ) November

CBC Individual November Registration

$55 2 workouts per week for 2 months for November

$55

 

*(  ) December

CBC Individual December Registration

$55 for two workouts per week for December

$55

(  ) CBC January and February

CBC Team January - February Training at Chesterfield Athletic Club

$55 per month for two workouts per week

$110

for 2 months

*Check the PlyoCity website for available workout times - will be updated 15 days before beginning of each month

 

PAYMENT ENCLOSED:

 

$ ____

Form of Payment:

Check: Check number: ____ (please make checks payable to PlyoCity)

Visa or MC

Credit Card Number (if applicable) _____________________________________

Exp. Date (month____/year____)

Name as it appears on Credit Card ________________________________

 

  Please Mail with check to: PlyoCity St. Louis PO Box 6471 Town and Country, MO 63006 (314) 878-3882

 

 

PLYOCITY REGISTRATION WAIVER AND RELEASE

 

For good consideration, the undersigned does hereby waive, release, acquit and forever discharge PlyoCity directors,     coaches and other club members, participants, volunteer parents, volunteer coaches, and any or all persons assisting with Plyometric Workout activities directly and indirectly associated with PlyoCity, and each of them from any and all known and unknown personal injuries and property damages which the player participant may suffer during the course of or as a result of Plyometric Workouts.

I, as a parent or legal guardian of ________________________________ (participant), also give my permission for this participant to receive minor medication when the need may arise. The trainer or other adult in charge may give this at the time. In case of emergency or in the case I cannot be reached, I authorize emergency treatment for my child at the nearest recognized medical facility.

 

PARENT/ GUARDIAN SIGNATURE: _________________________________ Date: _______