Coach Derek Refund Request/Credit Form

Instructions: PLEASE READ BEFORE YOU FILL OUT

  1. Please fill out this form completely and verify you have entered the correct information. Incomplete forms will delay processing of teh form.
  2. Please select the correct drop down boxes
  3. We use e-mail as our main form of communication. Please add our email address to your contact book so you do not miss anything. If you do not check your email regularly please add that to the comments section of this form!


Session

 Childs Name (First and Last)
   
Parents Name (First and Last)
 Best Telephone Number
Email
  
Current class enrolled in:
Please type below:
Day of the week, Time, Location, and Activity #
I am requesting:
Reason:

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.)