Send with check to:
James Fowler P.T., P.C.
44 Butler Place, #5J
Brooklyn, NY 11238
Phone: 718-638-7354

KIDSMOVE FOR SOCCER REGISTRATION

Child Name: ____________________________________

Date of Birth __________________________________

Address __________________________________________________________________________
                    Street                                             Apt                  City                                             Zip

Parents or Guardian Names:

1:______________________________________     2:_____________________________________

Home Phone ____________________________     Cell ___________________________________

Email:___________________________________

Classes (circle one)
4. y.o.    /    4-5 y.o.    /    5 y.o.    /    5-6 y.o.    /    6-7 y.o.    /    8-10 y.o.

Cost: $115 for 4 to 7 year olds      $150 for 8 to 10 year olds

MAKE CHECKS PAYABLE TO: JAMES FOWLER P.T. P.C.

I understand that, as with any other physical activity, it is possible that injury may occur. I understand and agree that if any injury should occur during class I shall hold KidsMove for Soccerî and all of its coaches, therapist, aides harmless for any injury and waive any claims or damages against them.