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The Pivot Event Registration

Name: The Pivot Event Registration
Start: 2023-01-27T19:14:06-06:00
End: 2023-01-27T19:14:06-06:00
Location: Madison Meadows Athletic Club

Saturday October 1, 2022 11:00 am – 5:00 pm

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Your Birth Date (month, day, year) *

Please identify your gender *

Male
Female

How will you participate in the Pivot event *

youth worker
spectator
player

Your Team Name (required if playing) *

Teammate name (required if playing) *

First

Last

Teammate name (required if playing) *

First

Last

Teammate name

First

Last

Teammate name

First

Last

Please select the appropriate age and gender of your team *

Consent for Promotional Purposes - permission to Leaders In Transformational Education (LITE) to use artwork, writing or pictures/videos taken at this event for the promotional purposes. I understand that refusal to sign this release will not affect delivery of service in any way. I am 18 years old or older/ I am a parent or guardian of a child under 18 years of age *

Consent
No Consent

All participants must Sign: I have read, understand and agree to the policies, notices, and procedures regarding the COVID Pandemic on the registration form. I will contact the LITE coaches immediately if I or someone I may have been in contact with is diagnosed with COVID within 14 days of this event. *

I/my child does not have a medical condition that I am aware of that prevents me / my child from participating in this activity. I agree to hold Leaders In Transformational Education (LITE) and any of its officers, employees, or volunteers free from any and all liability and waive all claims of damages or recompense for any accident, injury or disability to me or my property arising out of or connected with my participation in this activity/outing. I also authorize the Chief Executive Officer of (LITE), or duly designated representative, to secure the necessary medical, hospital and surgical attention, in the event of illness or physical injury to me/ my child during participation in this activity. By providing your signature below you have read and agree to the statement above. *

Free

Leaders In Transformational Education

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Madison Meadows Athletic Club

500 E Wilson Avenue
Lombard, Illinois 60148 United States

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