EmailMeForm
Margate - After School (off campus) 19
Leonard Weisinger Community Center
6199 NW 10th St, Margate, FL 33063
August 2019 - June 2020
PARENTS INFORMATION
Mothers Name
*
Fathers Name
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Mother's Cell Phone Number #1
*
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-
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Father's Cell Phone Number #2
###
-
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Mother's Email #1
*
Father's Email #2
CHILD INFORMATION
Enrollment
*
I am enrolling 1 child
I am enrolling 2 children
I am enrolling 3 children
#1: Childs First Name
*
#1: Childs Second Name
*
#1: Date of Birth
*
#1: Schools Name
*
#1: Grade
*
#1: Teachers Name
*
#1: Will your First Child need School Pick up?
*
Yes
No
#1: Food Allergies?
#1: Medical Conditions
CHILD #2 INFORMATION
#2: Childs First Name
#2: Childs Second Name
#2: Date of Birth
#2: Schools Name
#2: Grade
#2: Teachers Name
#2: Will your Second Child need School Pick up?
Yes
No
#2: Food Allergies?
#2: Medical Conditions
CHILD #3 INFORMATION
#3: Childs First Name
#3: Childs Second Name
#3: Childs Date of Birth
#3: School Name
#3: Grade
#3: Teachers Name
#3: Will your Third Child need School Pick up?
Yes
No
#3: Food Allergies?
#3: Medical Conditions
AUTHORIZED PICK UP
Who do you authorize to pick up your child after the program?
please list the names of the people you authorize to pick up your child.
(please note Drivers license needs to be presented)
REFERRALS
Who Referred you?
How did you hear about our program?
Who did you Refer?
For every person you refer, you will receive $5 voucher
* To be used within ALM Sports. (Fee's, Merchandise)
INSURANCE INFORMATION
Do you need ALM Sports Insurance?
*
Yes, include ALM insurance
No, my child has insurance as primary
ALM insurance will be billed $1 per day
Primary Insurance Details
(your childs insurance carrier and policy number)
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 $1.00 per day per sport. 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.
Total
$0.00