Name (Parent) *

First Name

Last Name

Phone

(###)

###

####

Which session(s)? *

Select the session(s) that you would like for your child to attend.

Session 1 (June)

Session 2 (July)

Session 3 (August)

How do you plan to pay today? *

ONLINE PAYMENT: I plan to pay full amount online via credit card below. (*$5 PayPal surcharge will be added to your total.)

MAIL-IN CHECK: I plan to mail in either a $50/child non-refundable deposit or the full amount of $150/child. *Deduct $25 for each additional child within the same family. (Make check out to BEKAH SELF, LLC.)

Liability Waiver *

Liability Release and Parental Consent Form: In consideration of the acceptance of my application for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in said event. This release is intended to discharge in advance Bekah Self, LLC, CustomFIT and FIT KID Camp, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees. Parental Consent (complete if applicant is under 18): I give consent for my child (whose name is listed above) to participate in the above activities, and I execute the above liability release on their behalf. Consent for Treatment: I hereby give my consent to have the above applicant treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that Bekah Self, LLC will provide no medical insurance for such treatment, and that the cost thereof will be at my expense. I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions.

I agree