EmailMe Form - After School Prg Installment Method

PARENTS INFORMATION

Mother's Name *

Father's Name

Address *

City *

State *

Zip Code *

Cell Phone Number #1 *

### - ### - ####

Cell Phone Number #2

### - ### - ####

Email #1 *

Email #2

CHILD #1 INFORMATION

#1: Childs Full Name *

Date of Birth *

School Name *

Grade *

Teachers Name *

Shirt Size *

Sport *

After Training

Parent Pick up

After Care

Bus

Other

Aftercare and/or Bus Name

CHILD #2 INFORMATION

#2: Childs Full Name

Date of Birth

School Name

Grade

Teachers Name

Shirt Size

Sport

After Training

Parent Pick up

After Care

Bus

Other

Aftercare and/or Bus Name

CHILD #3 INFORMATION

#3: Child's Full Name

Date of Birth

School Name

Grade

Teachers Name

Shirt Size

Sport

After Training

Parent Pick up

After Care

Bus

Other

Aftercare and/or Bus Name

CHILD #4 INFORMATION

#4: Child's Full Name

Date of Birth

School Name

Grade

Teachers Name

Shirt Size

Sport

After Training

Parent Pick up

After Care

Bus

Other

Aftercare and/or Bus Name

INSURANCE INFORMATION

Do you need A.L.M. Sports Insurance for your first child? A.L.M. Insurance cost $10 to cover the total program (training sessions + games) *

ALM Sports Ins for first child

No

Do you need ALM Sports Insurance for you second child?

ALM Sports Ins for second child

No

Do you need ALM Sports Insurance for your third child?

ALM Sports ins for third child

No

Do you need ALM Sports Insurance for your fourth child?

ALM Sports ins for fourth child

No

Primary Insurance Details
(your childs insurance carrier and policy number)

Medical Concerns

MEMBERSHIP PROGRAM (Sept '14 - Aug '15)

Applicable for all ALM Sports programs: Holiday Camps, After School Programs, Merchandise & More

Would you like your child to enroll in our membership program? *

Yes, membership for child

No, not at this time

Annual $50 membership fee (each child). For more info about our prg please contact us or visit prg page.

Would you like your second child to enroll in our membership program?

Membership for second child

No, not at this time

Would you like your third child to enroll in our membership program?

Membership for third child

No, not at this time

Would you like your fourth child to enroll in our membership program?

Membership for fourth child

No, not at this time

PAYMENT INFORMATION

Installment Payments *

*Indicate the date that you wish for your second payment to be charged, above. If left blank you will be charged full amount*

Please be advised that your first payment will be charged within 48 hours of form completion.

*All payments must be settled by Oct. 2nd or additional charges will incur.*

Card Type *

Visa

MasterCard

American Express

Name on Card *

Credit / Debit Card Number *

digits only / no dashes

Expiration Date *

CVV# *

last three numbers at the back of your card visa/mastercard

Is the card holders address the same as above? *

Yes

No

Address

City

State

Zip Code

TERMS & CONDITIONS

I have read and agree to the Terms of Service *

Yes, I agree.

If your child is covered by a private insurance, you must provide us with proof of your child’s insurance coverage. If your child is not, We offer this through WestPoint Insurers at a cost of $10.00 for the entire program. Please note; your Insurance fees covers both training & game days. I give consent for my child to take part in the activity and consent to emergency treatment as necessary. I accept that the organizers and their employees are not under any liability whatsoever in respect of injury, loss or damage whilst on the course, other than imposed by law. I also allow ALM Sports to take photos for advertising and promoting purposes only; if you do not want your childs photo to be taken please email admin@almsports.com. I confirm that my personal insurance is correct and bears responsibility in case of accidents. I confirm that I am legally entitled to give this consent and understand all payments received are non-refundable.