CORNFLAKES SUMMER CAMP JUNE 9–AUGUST 1 33 MONTHS–6 YEARS FIND OUT MORE ON PAGE 18
Technology Experience Camp
A new camp for grades 6–8 See page 20 for details!
YOUTH ATHLETICS Tiny Tumbler Sports Hot Shots Sports
Toddler Drop-in Gym (Tot Time)
This class introduces children to the very base fundamentals of sports. Participants will work on elements such as balance, kicking, throwing and catching. Adult assistance and participation is required. This class is great for both boys and girls.
Are you looking for a place to meet new friends and have your toddler exercise and run-off their energy? Tot Time is the place to do it. We have a balance beam, hoops, balls, scooters and much more for your child to use. Participants must wear gym shoes. No food is allowed. Parents must remain with children.
Dates: Days: 4/8–6/3 TU Class: Ages: 4022-2 1.5–3
Time: 11:00–11:30 a.m. Member: $152
NO CLASS: 5/6 Non-member: $182
Toddler Soccer Hot Shots Sports In this class young children develop motor skills while having fun running and kicking just like the big kids! Parents and tots work together in this class, learning the basics of soccer. Dribbling, passing, shooting and kicking will all be emphasized. A variety of activities designed around the game of soccer will be played each week. Dates: Days: 4/9–6/4 WE Class: Ages: 4021-4 2–3
Time: 10:00–10:30 a.m. Member: $152
NO CLASS: 5/7 Non-member: $182
Adult-Tot Sports Hot Shots Sports Parents are an integral part of helping their tots develop basic sports movement and motor skills. Activities focus on hand/eye and hand/foot coordination. Sports equipment and instruction are provided to help guide your child through this introduction to organized sports. Dates: Days: 4/7–6/2 MO Class: Ages: 4021-6 2–4
Time: 11:00–11:30 a.m. Member: $133
NO CLASS: 5/05, 5/26 Non-member: $160
Dates: Days: 4/10–6/5 TH Class: Ages: 4021-8 2–4
Time: 10:00–10:30 a.m. Member: $133
NO CLASS: 5/01, 5/08 Non-member: $160
Dates: Days: 4/9–6/4 WE Ages: Infant–5 $5 first child
Time: NO CLASS: 11:30 a.m.–1:00 p.m. Closed 5/7 $1 each additional child
Hot Shots Lunch & Play Hot Shots Sports Children are introduced to a variety of sports including soccer, tball, basketball, football, kickball as well as other sports and group games. The goal is to provide the opportunity for each child to develop motor skills and nurture his or her growth socially through teamwork and good sportsmanship. Kids should bring a lunch and come and play. Dates: Days: 4/7–6/2 MO Class: Ages: 4019-4 3–5
Time: 11:30 a.m.–1:00 p.m. Member: $245
NO CLASS: 5/05, 5/26 Non-member: $294
Dates: Days: 4/8–6/3 TU Class: Ages: 4019-7 3–5
Time: 11:30 a.m.–1:00 p.m. Member: $280
NO CLASS: 5/6 Non-member: $336
Dates: Days: 4/10–6/5 TH Class: Ages: 4020-0 3–5
Time: 11:30 a.m.–1:00 p.m. Member: $245
NO CLASS: 5/01, 5/08 Non-member: $294
Dates: Days: 4/11–6/6 FR Class: Ages: 4020-3 3–5
Time: 11:30 a.m.–1:00 p.m. Member: $280
NO CLASS: 5/2 Non-member: $336
SPRING | SUMMER 2014 Youth Athletics 25
Triple Play Hot Shots Sports
Little Hoopers 3Point Athletics
This class features three sports: football, soccer and basketball. Participants develop skills associated with each sport and have opportunities to use these skills in game situations. Emphasis is placed on skill development, teamwork and sportsmanship.
Specifically designed for kids, these 45 minute clinics are an introduction to basic basketball for the beginner. Classes will provide a comfortable and fun group environment as participants learn the fundamentals of the sport with an emphasis on dribbling and ball handling. 3Point’s engaging staff will emphasize activities that help develop basic motor skills, hand to eye coordination, and following directions. Each participant will receive a Little Hoopers t-shirt.
Dates: Days: 4/7–6/2 MO Class: Ages: 4022-0 4–6
Time: 1:45–2:45 p.m. Member: $175
NO CLASS: 5/05, 5/26 Non-member: $210
Dates: Days: 4/11–6/6 FR Class: Ages: Total Sports Hot Shots Sports Total Sports not only teaches children the basic skills of playing 4026-3 4–6
Time: 1:00–1:45 p.m. Member: $140
NO CLASS: 04/18, 5/02 Non-member: $168
particular sports, it also teaches them skills needed to work with one another as teammates and to accept each individual as a valu- Dodgeball Hot Shots Sports able player. Some of the sports taught and played include soccer, Dip, dodge, duck and throw! This class provides participants with kickball, football t-ball, floor hockey and basketball. an opportunity to play the popular game in a safe and supervised environment. The program uses super soft balls and safety will be Dates: Days: Time: NO CLASS: stressed. Each week players will learn new variations of the game, 4/9–6/4 WE 10:30–11:30 a.m. 5/7 Class: Ages: Member: Non-member: keeping class fresh and the kids having fun. Time limits are placed on all games so no participant ever sits out too long. 4020-8 3–5 $200 $240 Dates: Days: 4/10–6/5 TH Class: Ages: 4021-0 3–5
Time: 10:30–11:30 a.m. Member: $175
NO CLASS: 5/01, 5/08 Non-member: $210
Dates: Days: 4/7–6/2 MO Class: Ages: 4022-5 8–12
Time: 7:00–8:00 p.m. Member: $175
NO CLASS: 5/05, 5/26 Non-member: $210
Dates: Days: 4/11–6/6 FR Class: Ages: 4021-2 4–6
Time: 2:00–3:00 p.m. Member: $200
NO CLASS: 5/2 Non-member: $240
Dates: Days: 6/11–7/30 WE Class: Ages: 4031-1 8–12
Time: 5:00–6:00 p.m. Member: $200
Non-member: $240
Dates: Days: 6/9–7/28 MO Class: Ages: 4031-0 4–6
Time: 4:00–5:00 p.m. Member: $200
Non-member: $240
Dates: Days: 4/7–6/2 MO Class: Ages: 4020-5 6–9
Time: 6:00–7:00 p.m. Member: $175
NO CLASS: 5/05, 5/26 Non-member: $210
Indoor Floor Hockey Hot Shots Sports
Hockey fundamentals as well as game strategy, teamwork, sportsmanship and safety will be stressed each week. Players will learn key concepts, rules and fundamentals to allow them to get a jump start on the competition before hockey season kicks off. ParticiAll Sports Hot Shots Sports This class features a new sport each week. Some of the sports taught pants will be free to wear the following equipment: shinguards and and played include soccer, kickball, baseball, tennis and basketball. gloves (These items are not required). Boys and girls are welcome. The children have the opportunity to acquire new skills and de- Dates: Days: Time: NO CLASS: velop confidence in games they have played in previous classes. 4/7–6/2 MO 2:45–3:30 p.m. 5/05, 5/26 Class: Ages: 4022-4 4–7
Member: $175
Non-member: $210
“Game Time” Flag Football Hot Shots Sports
Players will experience daily scrimmages with active instruction and tips from the coaching staff of Hot Shots Sports. Coaches will referee while emphasizing the fundamentals and game strategies of flag football. Players will be encouraged to employ skills used in football such as running pass routes, play calling, defensive positioning, the fundamentals of blocking and pass coverage. These Lil’ Pigskins Hot Shots Sports Lil’ Pigskins is a national child development program that helps skills and others will be put to use in a “game time” environment kids discover the game of football. This program is designed for while the players scrimmage each week. children to learn about football, to have fun playing games with Dates: Days: Time: footballs and to increase their overall health. Our dynamic curricu- 6/9–7/28 MO 5:00–6:00 p.m. lum is safe, non-aggressive, child focused and comprehensive. Class: Ages: Member: Non-member: Dates: Days: 4/11–6/6 FR Class: Ages: 4020-6 5–8
Time: 4:30–5:30 p.m. Member: $200
NO CLASS: 5/2 Non-member: $240
Dates: Days: 4/10–6/5 TH Class: Ages: 4023-8 4–6
Time: 1:00–1:45 p.m. Member: $175
NO CLASS: 5/01, 5/08 Non-member: $210
26 Youth Athletics SPRING | SUMMER 2014
4031-3 8–12
$200
$240
Junior Soccer Academy: Champions
Junior Soccer Academy: Premier
Hot Shots Sports
Hot Shots Sports
Champions is the next step in the development for your young soccer player. The focus of the Champions classes is fundamentals that are crucial for every budding soccer player. Players focus on foot placement while shooting, following through on their shot, manipulating the ball in creative ways, defensive stance and much more, all while participating in our fun games and adventure-themed activities. In the Champions level, players will be given small tasks to do at home that are designed to enhance their soccer experience. A $35 Nike soccer kit fee is required at the first class (for first time participants). The Soccer kit includes a Nike Uniform; shirt, shorts, socks and Nike Soccer Ball.
Premier level is the top level of classes for your young soccer star. Player’s develop a close familiarity with the ball and learn the importance of always having it under control. Being geared towards getting your child ready for future soccer experiences, the Premier level class tests players in a more challenging environment working on one-on-one and team exercises. By the end of class your child will learn landing on their shooting foot, precision shots vs. power shots, trapping the ball in the air and field awareness. Like the Champions level, the Premier level players will also be given tasks to do at home to help further their development. A $35 Nike soccer kit fee is required at the first class (for first time participants). The soccer kit includes a Nike uniform (shirt, shorts and socks) and a Nike soccer ball.
Dates: Days: 4/7–6/2 MO Class: Ages: 4023-1 4–5
Time: 1:00–1:45 p.m. Member: $175
NO CLASS: 5/05, 5/26 Non-member: $210
Dates: Days: 4/10–6/5 TH Class: Ages: 4023-2 4–5
Time: 1:45–2:30 p.m. Member: $175
NO CLASS: 5/01, 5/08 Non-member: $210
Dates: Days: 4/11–6/6 FR Class: Ages: 4023-3 4–5
Time: 3:45–4:30 p.m. Member: $200
NO CLASS: 5/2 Non-member: $240
Dates: Days: 4/7–6/2 MO Class: Ages: 4023-4 5–6
Time: 1:00–1:45 p.m. Member: $175
NO CLASS: 5/05, 5/26 Non-member: $210
Dates: Days: 4/10–6/5 TH Class: Ages: 4023-5 5–6
Time: 1:45–2:30 p.m. Member: $175
NO CLASS: 5/01, 5/08 Non-member: $210
Dates: Days: 4/11–6/6 FR Class: Ages: 4023-6 5–6
Time: 3:45–4:30 p.m. Member: $200
NO CLASS: 5/2 Non-member: $240
Fencing Midwest Fencing Academy The Olympic sport of fencing demands a blend of tactical and strategic thought and a physical execution of those decisions. This has led many to describe the sport as “physical chess.” Fencing also teaches balance and discipline and even more than this, it’s fun! This class is for those new to fencing or those who would like to work on the basic skills. This class will cover basic rules, etiquette, basic footwork, attacks and defenses. Classes will consist of warm up time, footwork time, group lesson and bouting. All equipment is provided. Dates: Days: 4/16–6/4 WE Class: Ages: 4015-5 7 +
Time: 5:00–6:00 p.m. Member: $258
NO CLASS: 5/7 Non-member: $310
Dates: Days: 7/9–7/30 WE Class: Ages: 4031-4 7 +
Time: 5:00–6:00 p.m. Member: $148
Non-member: $178
Dates: Days: 8/6–8/27 WE Class: Ages: 4031-5 7 +
Time: 5:00–6:00 p.m. Member: $148
Non-member: $178
SPRING | SUMMER 2014 Youth Athletics 27
Meet our Youth Athletics instructors
Hot Shots Sports programs stress the pure enjoyment of being involved in athletics and offers the opportunity for children to develop their skills in an environment where everyone plays and reward is given for the effort rather than the result. Participants learn to have respect for each other on and off the court. Hot Shots Sports was founded in 1994 and continues to provide athletic programming in New York City, Denver and Chicago.
Mini-Majors Illinois Baseball Academy Staff This unique clinic is a fun-filled way for boys and girls to learn the athletic fundamentals and life skills through the great game of baseball. While our focus always ties back to baseball, our curriculum will include: Stretching and agility: training, developing young athletes through modern practices in dynamic stretching, strength development and injury prevention. Character development: assisting parents in raising thoughtful, well-adjusted children by teaching life lessons via children’s books and other select IBA materials. Baseball Instruction: teaching the proper fundamentals of the game to all participants enabling each to become progressively more competent and confident. Cross-sport Application: introducing young athletes to multiple sports that call for similar skills as the game of baseball thus insuring a sense of challenge, change and fun for each session. Dates: Days: 4/8–6/3 TU Class: Ages: 4024-7 4–5
Time: 1:00–2:00 p.m. Member: $120
NO CLASS: 5/6 Non-member: $144
Dates: Days: 4/9–6/4 WE Class: Ages: 4024-8 4–5
Time: 2:00–3:00 p.m. Member: $120
NO CLASS: 5/7 Non-member: $144
Illinois Baseball Academy employs some of the most accomplished and dynamic coaches on the North Shore, many with college and professional playing experience. Chris Beacom is the President of Illinois Baseball Academy. As a former New Trier head coach, Chris has been teaching children of all ages and ability levels how to play baseball for the past 20 years. Chris captained the Northwestern team and then played in the Toronto Blue Jays organization. All IBA instructors are trained in Illinois Baseball Academy methodology and share a commitment to making a positive impact on the players who come through our program.
MIDWEST FENCING ACADEMY
Hristo Etropolski is the head coach and owner of the Midwest Fencing Academy. During his career as a member of Bulgarian National Team he competed in the Olympic Games in 1980 and in 1988, placing fifth in 1980. He has won bronze and silver medals in different World Championships in both individual and team tournaments. During his best years as a competitor he won a number of World Cup tournaments and finished in the top eight in others. In 2005 he established Midwest Fencing Academy which quickly became one of the strongest saber clubs in the country.
Mini-Majors Rookie Level Mini-Majors Rookie Level adds additional challenge and higher level of instruction. Dates: Days: 4/8–6/3 TU Class: Ages: 4025-1 5–6
Time: 2:00–3:00 p.m. Member: $120
NO CLASS: 5/6 Non-member: $144
Dates: Days: 4/9–6/4 WE Class: Ages: 4025-2 5–6
Time: 1:00–2:00 p.m. Member: $120
NO CLASS: 5/7 Non-member: $144
28 Youth Athletics SPRING | SUMMER 2014
With 10 years of experience running quality instructional youth basketball programs in the Chicagoland area, 3Point Athletics is excited to continue bringing its dedicated and engaging staff to Winnetka Community House.
REGISTRATION INFORMATION Member registration opens March 17, 2014 and will be processed on a first come, first served basis. Membership does not guarantee placement in a class. All non-members will be able to register March 24, 2014. Registration received through the mail, fax, or in person will be processed by 5:00 p.m. the next business day. The best way to ensure that your registration is processed immediately is by using our online registration at winnetkacommunityhouse.org
Membership Information Early registration: Members are eligible to register for all classes one week prior to the start of seasonal registration. Early registration can be done via the web at winnetkacommunityhouse.org, fax or in person at Winnetka Community House. Please note: early registration does not guarantee a spot in a class. All family members in your household are eligible for membership benefits. When registering for membership, just list your family members, and they will be included for the program registration benefits automatically when registering for classes. Members receive a notice about one month prior to the expiration, so the membership can be renewed for the next year. Refunds for memberships will not be available.
Refund Policy Full refunds will be issued for courses that are cancelled by Winnetka Community House due to insufficient registration. A refund, less a 10% service charge (not to exceed $25), may be granted if the refund request is received five full working days prior to the start of the program. No refunds will be allowed after this time unless a medical condition develops and a written explanation from a physician on his/her letterhead is presented. Due to advanced reservation requirements, no refunds for trips, outings or special events will be given.
Prorated Policy Classes may be prorated if you would like to enroll in a class after it has started, provided the instructor has space and allows for late registration. The supervisor must approve the prorated amount.
Inclement Weather Winnetka Community House will not hold classes on days when the Winnetka Public Schools have cancelled classes due to inclement weather.
Religious Holidays
Winnetka Community House makes every effort to avoid scheduling programs or events on religious holidays. Anyone affected will be offered the option of attending a session of the same program on a different date as a make-up, or receiving a prorated refund of the series fee for the date missed. • Winnetka Community House is not responsible for the supervision of How To Register children on site prior to or remaining on site after the established program • To register for a membership simply list all eligible members on the registratimes. tion form. Then check the box and add the membership fee in with • Winnetka Community House is handicapped accessible. your registration. • If you or any member of your family has special needs, please see our • Register for programs online at winnetkacommunityhouse.org or on the Executive Director. enclosed registration form. • Winnetka Community House receives no tax dollars. We are supported by • Please print clearly. our programs, fund raising events, our annual campaign, and donations. • Read and fill out form completely. • Winnetka Community House assumes no responsibility and carries no • By listing your email address, you agree to receive email communications accident or medical insurance for injuries or accidents at programs or from Winnetka Community House. We will never sell your address, but activities on Community House property. It is advisable to review your love to keep in touch with our users to give news about programs, events, own personal health insurance plan to be certain that you and your family and special offers from Winnetka Community House. If you do not wish have proper and sufficient insurance coverage. to receive these emails, please unsubscribe. Brochure Errors • Sign the registration form. • Unsigned forms will not be processed, but will be returned to you. This Complete details of program policies, procedures, and guidelines are sometimes inadvertently omitted. Errors in days, times, registration will delay processing your registration. • Registration forms may be mailed or faxed. Registration by telephone is requirements and fees may occur in the brochure. When such errors occur the staff will advise you of the change as quickly as possible. We thank you not accepted. for your understanding.
Credit Cards
You may use your credit card for all programs which appear with a class Copy And Fax Service Available number or for a Fitness Centre membership. Fitness Centre memberships Copy service is available at $0.10/copy. Fax service is available at $2/first are obtained at the Fitness Centre only. Be sure to fill out the credit card page and $1/each additional page. Cost to receive a fax: $1/page (Faxes are information completely and sign the form. We do not take telephone limited to 847, 312, 773, 708, and 630 area codes) registration. However, if you are paying by credit card, you may fax your registration to (847) 446-0609.
Cancellation of Classes Prior to any class, registration is reviewed to determine if the enrollment is sufficient to hold the class. Register early! Do not wait until the day of the first class to register. You may find the class has been cancelled due to low enrollment.
Winnetka Community House asks that all participants be courteous to our neighbors when driving and parking in the area.
STEPHEN DUSTMAN MEMORIAL SCHOLARSHIP FUND
Winnetka Community House has established the Stephen Dustman Memorial Scholarship Fund to any resident who would like to take part in a Winnetka Community House activity, but is unable to render full payment. Persons interested may submit their need in writing to the attention of the Executive Director for confidential review. If further information is desired, please call our main office. Donations to this scholarship fund are gratefully accepted. 48 Registration SPRING | SUMMER 2014
Become a
WI NNETKA
C OM MUNITY HOUSE
Member!
Step 1
Register your whole family!
A one year Community House Membership is $150. All family members in your household are eligible for membership benefits. When registering for, just list your family members, and they will automatically be eligible for benefits when registering.
Step 2
Register early for programs!
Registration begins a week early for Community House Members. Check out our website or program guide for member registration dates.
Step 3
Save money on classes!
Members save up to 20% on registration! Find the Member price listed for each program and save on your whole family’s programs all year!
Note: Membership does not guarantee placement in all classes. Some classes fill quickly.
Don’t forget!
Members also receive special offers and rewards throughout the year! Watch your email for Member’s Only specials on programs, events and more!
Winnetka Community House Membership Program To sign up for a membership, please list all members of your household below and fill out a registration form. If registering for a class, please add $150 to your total registration fee. If signing up for a membership only, your $150 membership fee can be paid by check or credit card. Register online at winnetkacommunityhouse.org. Name
Birth Date
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Birth Date
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Sex
Name
Birth Date
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Sex
Name
Birth Date
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Sex
Name
Birth Date
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Sex
Name
Birth Date
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Please note: Membership specials are delivered via email. By becoming a Community House member you agree to receive emails from Winnetka Community House including our monthly email newsletter. To customize your email preferences, please visit winnetkacommunityhouse.org.
WINNETKA COMMUNITY HOUSE 847-446-0537 W I N N E T K A C O M M U N I T Y H O U S E . O R G 6 2 0 L I N C O L N AV E., W I N N E T K A I L 6 0 0 9 3
SPRING | SUMMER 2014 Registration 49
R E G I S TRAT ION FORM
Register online at winnetkacommunityhouse.org, via fax at 847-446-0609 or mail this form with payment in full to: Registraiton - Winnetka Community House, 620 Lincoln Ave., Winnetka, IL 60093. Contact us by phone at 847-446-0537 with any questions. Please print.
CONTACT INFORMATION PA R ENT/GUA R D I A N’ S LA S T N A M E:
PAR E N T/ G U AR D I AN ’ S F I R S T N AM E :
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S TATE :
Z IPCODE:
I WOULD LIKE TO RECEIVE NEWS FROM THE WCH
E MAIL : E MERGE NCY CO NTA CT NAM E:
E M E R G E N C Y C ON TAC T P H ON E :
PARTICIPANT INFO F ULL NA M E
CLASS INFO B I RTH D ATE
M/F
SCH OOL
CL ASS CODE
CL ASS NAME
FEE
$150
I would like to register for a Community House Membership! Please list all family members on the reverse side of this form
I would like to make an annual fund donation. TOTAL CA S H
VI S A
CA R D N UM B E R
CHECK
M A S TE R CA R D
T O TA L PAY M E N T
E XP. DATE S I G N ATU R E
Winnetka Community House is committed to conducting its recreation programs and activities in the safest manner possible, and holds the safety of the participants in the highest possible regard. Participants and parents registering their child in recreation programs must recognize, however, that there is an inherent risk of injury when choosing to participate in recreation activities. Winnetka Community House continually strives to reduce such risks, and insists that all participants follow safety rules and instructions which have been designed to protect the participants’ safety. Please recognize that Winnetka Community House does not carry medical accident insurance for injuries sustained in its programs. The cost of such would make program fees prohibitive. Therefore, each person registering himself\herself or a family member for a recreation program/activity should review his/her own health insurance policy for coverage. It must be noted that the absence of health insurance coverage does not make Winnetka Community House automatically responsible for payment of medical expenses. Due to the difficulty and high cost of obtaining liability insurance, the agency providing liability coverage for Winnetka Community House requires the execution of the following Waiver and Release. Your cooperation is greatly appreciated. Please read this form carefully, and be aware in participating in the program(s) listed on this page, you will be waiving and releasing all claims for injuries you might sustain arising out of the activities of this program. WA I V ER A N D RE L E A S E O F ALL CLAIMS As a participant in the program, I recognize and acknowledge that there are certain risks of physical injury, and I agree to assume the full risk of any injuries, including death, damages or loss, regardless of severity, which I may sustain as a result of participating in any and all activities connected with or associated with such program. I agree to waive and relinquish all claims I may have as a result of participating in the program against Winnetka Community House and its officers, agents, servants and employees. I do hereby fully release and discharge Winnetka Community House and its officers, agents, servants and employees from any and all claims from injuries, including death, damages or loss which I may have or which may accrue to me on account of my participation. I further agree to indemnify and hold harmless and defend Winnetka Community House and its officers, agents, servants and employees from any and all claims from injuries, including death, damages or losses sustained by me or arising out of, connected with, or in any way associated with the activities of the program. In the event of emergency, I authorize Winnetka Community House officials to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary for my immediate care, and agree that I will be responsible for payment of any and all medical services required. All participants agree that any photography taken while participating in a class, special event or use of a facility may be used for promotional purposes Winnetka Community House. Participants agree to receive emails from Winnetka Community House. R EF U ND A N D P RO RAT E I N FOR MAT ION Full refunds will be issued for courses that are cancelled by Winnetka Community House due to insufficient registration. A refund, less a 10% service charge (not to exceed $25), may be granted if the refund request is received five full working days prior to the start of the program. No refunds will be allowed after this time unless a medical condition develops and a written explanation from a physician on his/her letterhead is presented. Due to advanced reservation requirements, no refunds for trips, outings, or special events will be given. Classes may be prorated if you would like to enroll in a class after it has started, provided the instructor has space, and allows for late registration. The supervisor must approve the prorated amount.
Please list any specific medical allergies, medications, chronic illness or other conditions which staff should be aware of:
Winnetka Community House operates in compliance with the Americans with Disabilities Act. If you believe you or your child need accommodations to facilitate participation in Winnetka Community House program(s) for which you are registering, please check box.
I have read and fully understand the aforementioned Program Details, Waiver and Release of All Claims and Permission to Secure Treatment. S IG NATURE:
D ATE : R e g i st r at i o n fo r m w i l l n o t be pr o c e sse d w ithou t w a iver s igna tu re.