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Class Registration Form Soccer

 
 

GRADES K - 5 • Tuesday AND Wednesday
Grades K - 2 / 4-5pm 
Grades 3 – 5 / 5-6pm
Session 1: January 15 - March 5 (15 sessions / $180)
Session 2: March 19 - May 14 (15 sessions / $180)
 

Age 3 - 5 • Tuesdays
Age 4-5: 2-2:45pm | Age 3: 3-3:40pm 
January 15 - April 30 (15 sessions / $180)

PLEASE COMPLETE THE FORM BELOW TO REGISTER

 
Please Choose One:
 JCC Member
 Guest Participant
 Neshama Member
Membership Number (If applicable):

JCC Membership will be verified by Alper JCC administration upon receipt of registration form.

Participant Name*:
Date of Birth* (mm/dd/yy):
Enrolled In
 ECD
 ASP

 

Class/Program 1


 

Class/Program 1

 

Class/Program 2


 

Class/Program 2: (optional)

 

Contact Information


 

Address*:
Address2
City*:
State
Zip
Email*:
Home Phone*
Work Phone
Cellular*:

 

Child registration


 

Parent #1
Parent #1 Date of Birth (mm/dd/yy)
Parent #1 Cellular
Parent #2
Parent #2 Date of Birth (mm/dd/yy)
Parent #2 Cellular

 

Waiver


 

WAIVER AND RELEASE- PLEASE READ CAREFULLY

I, on behalf of myself and my family (“I”), the undersigned, upon participating in programs at the Dave and Mary Alper Jewish Community Center, Inc. (“Alper JCC”) agree to abide by the policies, rules, and by-laws of the Alper JCC. I understand that participating in a program may be limited or terminated upon violation of these rules. I understand that engaging in the different activities and programs at the Alper JCC, or otherwise connected with the Alper JCC, are done at my own accord, and that it is my sole responsibility to ensure that I am int he proper physical condition to engage in such activities or programs. I understand and acknowledge that participation in the programs offered by the Alper JCC, or otherwise connected with the Alper JCC, could in some circumstances result in physical injury, including death, despite all safety precautions, and that I assume all risks and hazards incidental to the programs or activities in which I engage. I hereby release, indemnify and hold harmless the Alper JCC and any and all of its servants, agents, contractors or employees, including but not limited to any and all of the instructors of any and all programs offered by the Alper JCC or connected with the Alper JCC, from and for any and all actions or causes of actions, claims, damages, demands by the registrants heirs/executors, administrators or assigns, for, upon, or by reason of any damage, loss or injury (including death) to the registrant or their property which may be sustained as a consequence of the registrant attending at or participating in any and all of the programs, or any other activity connected with the Alper JCC, including use of the facilities and equipment and transportation to and from these programs, notwithstanding any such damage, loss or injury (including death) may have arisen out of the negligent acts or omissions or the gross negligence of the Alper JCC, and any and all of its servants, agents, contractors or employees, including but not limited to any and all of the instructors of the programs. I understand and acknowledge that the Alper JCC is not liable for any loss, damage or theft of personal property wheresoever located, and not limited to personal property left in lockers, storage, parking lot or in any other area of the Alper JCC and I hereby expressly waive any claim(s) which I may have against the Alper JCC arising from or as a result of any such loss, damage or theft. I permit the free use by the Alper JCC in any manner whatsoever of my name and family members' name(s) and photos, without compensation paid to me or my family members. If the participant is under the age of eighteen (18), this form must be signed by a parent/guardian. 

 

THESE DEPARTMENTS REQUIRE SEPARATE REGISTRATION. PLEASE CONTACT THEM DIRECTLY

Danny Berry Baseball x241, Jane Forman Tennis x291, Martial Arts x276, Miami Children’s Theater x400, Miami Select Volleyball, 786.325.4063

 

PHOTO AND INTERNET/SOCIAL NETWORKING RELEASE: I hereby give the Dave and Mary Alper Jewish Community Center and all persons acting with its permission the absolute right and unrestricted permission to obtain, use, copyright and/or publish photographic portraits or pictures of the above named registrant, in conjunction with the registrant’s own name or another fictitious name whether such are still, moving, single, multiple, or with others. It is my understanding that such picture(s) are for the purpose of art, advertising, trade, inclusion in social media and any other lawful purpose whatsoever. I understand further that I will not have any opportunity to approve or review the finished product that may be used in connection there with or the use to which it may be applied. 

Initial Here
Emergency Contact Name
Emergency Contact Phone
Physician Name
Physician Phone
Photo Release (Type "Yes" or "No")
Initial Here

 

Payment


 

Card
Name of Card
Number
CVV
Expiration

11155 SW 112 Avenue, Miami FL 33176
305.271.9000

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