Name of Participant *

First Name

Last Name

Date of birth

MM

DD

YYYY

Start Date

MM

DD

YYYY

Class time

Hour

Minute

Second

AM PM

Contact Information for Participant

Enter parent name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home phone

(###)

###

####

Cell phone or best number to be reached

(###)

###

####

First emergency contact

First Name

Last Name

Second emergency contact

First Name

Last Name

Waiver of Participant by parent or self *

In consideration of your accepting my or my child’s registration and entry, I hereby for myself, my child, my heirs, executors and administrators, waive and release any and all rights and claims for damages I or my child may have against The Town of Westport,The Field House, Growing Tree Yoga,LLC, or Sara Holland; and its representatives, successors and assigns, for any and all injuries suffered by myself or my child at the activity sponsored by these groups. I understand there is inherent risk associated with the(se) activity(ies) and authorize emergency medical treatment and transportation in my absence. If any of the above participants are minors, I certify by my signature that I am the custodial parent or guardian; or I have the expressed authorization of the custodial parent, or guardian to enroll said participant(s) in the specified activities listed.

I agree

I do not agree

Sara Holland Sports, Compass Sports Academy, LLC, has my permission to use my or my child’s photograph publicly to promote the camps and clinics. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Yes

No