Take Off Klub Registration

Take Off Klub Registration
Name

First Name Last Name
Sex (M/F)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number
Date of Birth *

Month Day Year
Date
Marital Status (married, single, divorced, widowed)
Date of last physical (approximate)

Month Day Year
Date
Are you medically cleared for physical activity
List any medical conditions and/or current medications
Emergency Contact

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Please read before signing!

By signing this form, I certify I am physically fit, completed a physical within the last year, and I am able to participate in the strenuous activities that will be provided by Flight Tyme. I also understand that there are inherent risks with all physical activity, and therefore, will hold Flight Tyme and its instructors harmless in the event I suffer any injury while involved in the camp. In the event I am injured, I also authorize Flight Tyme to seek medical attention, including permission to have me transported to the nearest medical facility for treatment.
Signature
Date

Month Day Year
Today's Date
Photos and videos will be taken for future promotional use for Flight Tyme’s purposes only. By signing here you approve of Flight Tyme’s promotional use of you/your child’s image on its website and future promotions.
Signature
Date

Month Day Year
Today's Date
Should be Empty: