Coach Derek Youth Sports - Registration Form

Parents Name (First and Last)	Relationship

Parents DOB (mm/dd/yr)

Child's Name (First and Last)	Child Gender



Child's DOB (mm/dd/yr)	Mailing Address

Home Telephone Number	Mobile Telephone Number

Email	New or Returning Student

Does your child have any special needs?	If yes, please explain


Registration Fee	Total Amount Due

Session	Session Day

Session Time	Park/Location:

I have read the Coach Derek Inc. (CDI) FAQ and Policies and agree to them
Please note in the comments if your payment will include registration fee or any discounts. Please also give us any information about your child that will help us facilitate the best class for him or her! Comments
Payment to be made by: We currently only accept Cash, Check and Gift Certificates.
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.