Wonder Bus Registration

Email^*

Enter email again^*

Parent/Guardian's Name:^*

Parent/Guardian's Contact Number:^*

Billing Address:^*

Street Number

Street Address

City

State

Country

Zip Code

Is Your Child a Returning Participant?^*

Child's Name:^*

Child's Date Of Birth:^*

Child's Grade (While Participating in the Program):^*

Child's Gender:^*

Emergency Contact's Name:^*

Emergency Contact's Number:^*

Emergency Contact's Relationship to Child:^*

Is this child allergic to any medications?

Does this child have any medical history that you feel we should know about?

The following information is confidential and will be used solely for future program and funding opportunities.

Child Lives With:^*

Both Parents
Mother Only
Father Only
Legal Guardian

Consent and Release:^*

My child/legal ward has permission to participate in Premier Athletics for Youth Development programs. I hereby release and wave any and all claims against Premier Athletics for Youth Development and any agents, representatives, officers, board of directors, coaches, and other personnel of the same; from any responsibility of liability or liability for any injury, loss or damage which may hereafter be suffered or sustained by my child arising out of their playing or participating in this program. This includes but is not limited to competing in sports, traveling to or from any games/events, practice, or activities sponsored by Premier Athletics for Youth Development or while a spectator at any games, practices, or events. I authorize the head coach of my child’s team, Premier Athletics for Youth Development staff, or emergency personal to seek and/or provide medical attention for my child if I cannot be contacted.

I have read and accept the terms within the consent and release.

Model Photo Release:^*

I, for good and valuable consideration, the receipt of which is hereby acknowledged, hereby irrevocably authorize Premier Athletics for Youth Development to use photographs of me, my child, and/or my property and authorize their assignees, licensees, legal representatives and transferees to use and publish (with or without me or my child’s name, company name, or with fictitious name) photographs, pictures, portraits or images herein described in any or all forms and media and in all manners including composite images or distorted representations, and the purposes of publicity, illustration, commercial art, advertising, publishing (including publishing in electronic form in DVDs or internet websites), for any product or services, or other lawful uses as may be determined by Premier Athletics for Youth Development. I further waive any and all rights to review or approve any uses of the images, any written copy or finished product. I am of full legal age and have read and fully understand the terms of this release. I am the parent or guardian of the minor named above. I have the legal rights to consent to and do consent to the terms and conditions of this model release.

I have read and accept the terms of the Model Photo Release.

Wonder Bus Summer Program^*