Player's Name* First Last Parent's Name* First Last Names and grades of your other childrenHome Phone*Cell Phone*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* SchoolBirthdate(mm/dd/yyyy)GradeEmergency Contact Name/Number*Names of People child can be discharged toList physical/mental conditions or known allergies (We do not administer any medication)Selected ProgramPlease enter your price* Total $0.00 Dates of Program Registering For:(mm/dd/yyyy)Please Select Your Method of Payment*Cash - Email Chad@CMEK.comCheck - Mail to: PO Box 526 Englewood, NJ 07631Credit CardPaypal - Chad@CMEK.com is the accountVenmo - Chad-Mekles is the handleThere 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 .Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Policy Agreement*I agree that I am taking a spot in a CMEK program. In the event of an injury, I understand that all refunds will be in the form of credit to a future CMEK camp program. I agree that you may utilize photographs, testimonials, email addresses, and information relating to my child's participation in CMEK activities on your web site and other CMEK publicity 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.
