Special Event/Private Lesson Registration Form



Event Type
 Parents Name
Telephone -contact 1
 Telephone -contact 2
Email
 Day of the week
Childs Name
 Childs Age
Day of the Week
 Time
Age Range of Participants
 Coach Preference
Sport(s)
 Location

Please describe your event below:
Comments

By hitting the submit button you agree to the follow Coach Derek's policy.

I, the undersigned participant, parent, or guardian, do hereby agree to participate and/or allow the individual(s) named herein to participate in the aforementioned activity(ies) and further agree to indemnify and hold harmless Coach Derek, Inc., its agents and employees from harm, accidents, personal injury or property damage which may be suffered by the aforementioned individual(s) arising out of, or in any way connected with the participation of the activity.

Register online and MAIL PAYMENT TO: Derek Locklear PO Box 1260 Manhattan Beach, CA 90267

(Checks payable to Coach Derek, Inc.)