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1Member Info

2Medical Info

3Release of Liability & Waiver

4Payment

Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant Information

Child's Name*

First Last

Child's Date of Birth*

Month

Day

Year

Grade*

(as of upcoming school year)

Medical Information

Family Doctor*

Phone*

Insurance Company*

Policy Number*

Please list any previous injuries, physical conditions or weaknesses that may affect the athlete Condition/Injury*

Medical Authorization and Liability Release*

I authorize COA Elite and its representatives to consent to medical treatment for my child when I cannot be reached to give consent. I am fully aware that any activity involving motion, height, or athletic exercise creates the possibility of serious injury, paralysis, or even death. I further agree to hold COA Elite and its staff harmless for any injury or resulting expense(s). I release and discharge all rights and claims against COA Elite, and its parties. COA Elite strives to provide the maximum in safety procedures and guidelines, and cannot assume responsibility for any accidents, injuries or illness that may occur.

Authorization to obtain medical treatment if necessary for athlete (18 or older) or authorization from parent or guardian if he/she is not available to make this decision (if under 18).*

I give FULL PERMISSION to COA Elite LLC, its Owner(s), Director(s), Staff, Employee(s), Independent Contractor(s), and/or Volunteers, the legal right to choose or decide what medical attention be provided, should the need arise, when the athlete(s) cannot make this decision (if under 18 years of age) or parent/guardian for the athlete(s) under 18 years of age is not present to make this decision.

Parent Consent*

The athlete listed above has my permission to participate in the COA Elite program. In consideration for the training and coaching provided by COA Elite and its staff, I understand that my son/ daughter must abide by the rules and regulations set forth by the coaches and staff. I understand that violations of any of these rules may result in removal from the classes and or events. We acknowledge and recognize that hazards are present in any athletic event and that injury may result. COA Elite coaches, staff and volunteers will not be liable for injury that occurs during practice, contests, or travel to and from activities.

Signature*

Payment Information

Trial Registration*

Trial memberships are non-refundable and must begin within 30 days of purchase.

Price:

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Credit Card*

Card Details

Cardholder Name

Step 3: Purchase Trial Membership

Participant Information

Medical Information

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