Training Young Champions
704.840.8936
Lisa@Fit180Athletics.com
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Register for Winterfit
Registration: WinterFit
Step 1 of 5 - Athlete Information
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Select Your Program
*
WinterFit
Select Location
*
Marvin Efird Park - Jan 7 - Feb 1
Community House MS - Jan 23 - Feb 15 (Mon, Wed, Fri) 4:30 - 5:30 pm
Select which location you would like to attend.
Athlete's Information
Please fill out all of the required fields in this section.
Athlete's Name
*
First
Last
Gender
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Male
Female
School
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Grade
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Select Grade Level
3rd
4th
5th
6th
7th
8th
9th
Date of Birth
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First Time Registration?
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This is the FIRST TIME my athlete has participated in any Fit180 Program
Athlete HAS PARTICIPATED in a former Fit180 program.
If you have already completed a registration for this athlete for a former program, you can choose to SKIP or UPDATE your Contact and Medical Information.
Has Your Medical and Insurance Information Changed?
*
NO. My Medical Information has not Changed. Skip this section.
Yes. I need to UPDATE or PROVIDE medical information
This includes relevant conditions, critical allergies, over-the-counter medication, insurance and Doctor information. If nothing has changed since your last registration, please select No.
Contact Information
Primary Email Address
*
Enter Email
Confirm Email
Additional Email Address (Optional)
Enter Email
Confirm Email
Please enter any additional email that you would like to be included in the correspondence.
Mother's Name
First
Last
Mother's Cell Phone
Father's Name
First
Last
Father's Cell Phone
Address
*
Street Address
Address Line 2
City
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Connecticut
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District of Columbia
Florida
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Maine
Maryland
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South Carolina
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Tennessee
Texas
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Vermont
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Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Other Authorized Guardian
*
All authorized guardians are listed above
I wish to authorize another authorized guardian for pickup/drop-off
Guardian's Name
First
Last
Cell (Additional Guardian)
Medical & Insurance Info
Medical Information
Please fill out all fields in this section
Medical or Allergy Conditions
*
My child has NO medical or allergic conditions that you need to be aware of.
My child has a medical or allergic condition you need to be aware of.
By signing this form, you are affirming that our child is medically and physically fit to take part in strenuous exercise. However, if there is anything we should know regarding allergies, medicine, or medical conditions, please select the second option and let us know.
Please list anything your child is allergic to (drugs, pollen, nuts, etc):
*
Does your child have any of the following?
Asthma (incl. exercise-induced asthma)
Diabetes
Epilepsy
Is your child currently taking any medications that we should be aware of?
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Yes
No
Please list those medications:
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Is there additional information we should know about your child's health or physical condition?
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Yes
No
Also use this to explain any conditions listed above.
Please explain:
*
Insurance Information
Please fill out all fields in this section.
Name of Insurance Company
*
Policy Name and Number
*
Physician's Name
*
Dr's Phone
*
Informed Consent and Terms & Conditions
Authorization for participation and emergency treatment.
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I hereby give permission for my athlete (Named Above), to participate in Fit180 Athletics programs. Further, I authorize the club to provide emergency treatment of any injury or illness my child may experience if qualified medical personnel consider treatment necessary and perform the treatment. This authorization is granted only if I cannot be reached and reasonable effort has been made to do so. My child and I are aware that participating in conditioning, track and field and cross country is a potentially hazardous activity. We assume all risks associated with participation in this sport, including, but not limited to falls, contact with other participants and other reasonable-risk conditions associated with the sport. All such risks to my child are known and understood by my child and me. We understand this informed consent form and agree to its conditions.
Image Release
*
In consideration of my minor child/ward being allowed to participate in any way in the Fit180 Athletics Club program, related events and activities, the undersigned agrees that such participants’ likeness may be photographed or videotaped and that such image may be published in our outlet used to promote or publicize the sports program.
Terms and Conditions
CODE OF CONDUCT Parents • Be a positive role model. • Encourage good sportsmanship among all athletes. • Be supportive of coaches and meet officials. • Respect the coach’s ability to teach and coach your child. Parents may discuss the training program with coaches following practice, if time permits. It is recommended that parents schedule time separate from practice to meet with the coach to discuss concerns. • Arrive to meets at the time given to you by the coach and check in at the designated team area. • Place the physical and emotional well-being of your child above any personal desire that they have to win. • Remember, children are involved in organized sports for their enjoyment, not ours. Be supportive and encourage them to enjoy themselves and to do their best. Athletes • Arrive at practice ready to listen, work hard, learn and give my best effort. • Do your best to be at every scheduled practice. Be on time and prepared. Late athletes will not be allowed to participate in training activities without completing a warm-up. Practices will not be delayed or extended to accommodate late arrivals. • Learn the rules and always compete by them. • Be respectful of coaches, officials, parents, teammates and competitors on other teams. Treat others as you wish to be treated. • Inappropriate behavior and/or language will not be tolerated. Conduct which is not in compliance with the Code of Conduct and/or which is detrimental to the club may result in an athlete's dismissal from the club. FEES WILL NOT BE REFUNDED IN THE EVENT OF DISMISSAL CANCELLATION POLICY for all Fit180 Programs. Cancellation Fee: There will be a $10 Cancellation Fee for any refund of funds at any time after payment has been received. Maximum Refund will be: (a) If more than 48 hours prior to the start of the program, you will receive a full refund, minus cancellation fee (above), and any other expenses that have been applied, such as uniforms, race fees, etc.., or (b) if after 48 hours prior to start of the program, Maximum refund will be 50% of total program fees. Fit180 Athletics holds the right to further prorate the refund based on the actual participation of the athlete, and expenses incurred. At no time will the refund be greater than 50% of total program fees.
Signature of parent or guardian
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Type in your full name for an electronic signature. By signing above, you agree to the Terms and Conditions, Image Release, and Authorization for Participation as detailed above.
Options and Payment Method
Payment Method
*
Pay by Check
PayPal*
* There is a $4.00 charge for PayPal to help cover merchant account fees.
Please make checks payable to Fit180 Athletics and take to the first practice. Or you can mail it to: Lisa Sluiter Fit180 Athletics 2436 Logan Field Dr. Waxhaw, NC 28173
Name
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Training Young Champions
Training Young Champions
