Club Incline Registration

First Name of Son *

Last Name *

Grade Level for Current Academic Year *

Date of Birth *

Month *

Day *

Year *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Father's Name

Home Phone *

Father's Cell Phone

Father's Email *

Secondary Email (for duplicate contact)You may enter a secondary email address if you want the same information about the program sent elsewhere.

Medical Release *Should the need arise, permission is granted to provide medical assistance to my son. By entering your name in the box above, you are signing as a parent or legal guardian.

Photo ReleaseI agree to grant to CAPSTONE and its authorized representatives permission to record on photography film and/or video, pictures of my participation. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, or other printed materials used to promote CAPSTONE, and further that such use shall be without payment of fees, royalties, special credit or other compensation.

Comments