Player 1 Name* First Last Player 1 Grade Player 1 Birthdate(mm/dd/yyyy) Player 2 Name First Last Player 2 Grade Player 2 Birthdate(mm/dd/yyyy) Player 3 Name First Last Player 3 Grade Player 3 Birthdate(mm/dd/yyyy) Player 4 Name First Last Player 4 Grade Player 4 Birthdate(mm/dd/yyyy) Parent's Name* First Last Names and grades of your other childrenHome Phone*Cell Phone*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* School Emergency Contact Name/Number*Names of People child can be discharged toList physical/mental conditions or known allergies (We do not administer any medication)Selected Program Please enter your price* Total $0.00 Dates of Program Registering For:(mm/dd/yyyy) Please Select Your Method of Payment* Cash - Email Chad@CMEK.com Credit Card Paypal - Chad@CMEK.com is the account Venmo - Chad-Mekles (comment with Child's name, grade,school) There is a 3% credit card fee if you select payment by Credit Card or PayPal.If you are paying by Venmo, our Venmo handle is Chad-Mekles .HiddenDate of Form Being filled In MM slash DD slash YYYY Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Policy Agreement*I agree that I am taking a spot in a CMEK program. I understand that there are no refunds. In the event my child cannot participate due to an injury, sickness, or any other conflict, a pro-rated credit will be issued. The credit may be used towards a future school break or summer camp program only and does not expire. I agree that CMEK may utilize photographs, videos, testimonials, email addresses, and information relating to my child's participation in CMEK activities on the CMEK web site, various Social Media platforms and literature. I hereby authorize the agents of CMEK ALLSTARS INC., to act for me according to his/her best judgment in any emergency requiring medical attention. I hereby release, discharge and indemnify CMEK ALLSTARS INC., staff, affiliated entities and their officers, agents and employees, from and against any and all claims, liability, causes of actions, lawsuits or awards arising out of or in connection with my or my child's participation in the program. I agree that program locations and times are subject to change based on availability, inclement weather, and enrollment. I have read the CMEK code of conduct with my child and promise to abide by it. I authorize this form to be used and updated accordingly for all CMEK programs that my child participates in for all future CMEK programs. I Agree. After clicking Submit you will be directed to PayPal to complete your payment. Δ
