CIRCUS OF THE KIDS

Registration Form for
Levite JCC in Birmingham, AL.
Sun, Jun 23rd, 2013 through Sat, Jun 29th, 2013

On Sunday, June 23 at 3:30 PM there are MANDATORY AUDITIONS for campers and an Orientation Meeting for their parents at the JCC. Campers who do attend the audition risk forfeiting their circus position.

⁽*⁾ - denotes required field

Total number of children (siblings) being registered⁽*⁾:

First Name *⁽⁾**	Last Name *⁽⁾**
Birth Date *⁽⁾**	Birth Date Instructions: You can either enter the Birth Date directly into the text field (Please format as: Jan 11, 1995 or Aug 5, 2001), or use the calendar widget (choose month and year first, press OK, then choose day). If you need to change the year after your initial selection, just press on the month or year at the top of calendar. Gender *⁽⁾** Boy Girl

COTK ALUMNI ONLY
Where did you participate in COTK last?
Year
List up to 3 act preferences (does not guarantee request)

List ALL acts performed with COTK

Grade *⁽⁾**	E-mail Address *⁽⁾**

Previous Experience (i.e. circus, gymnastics, dance)
Where? When? How Long?

The more we know about you, the more effective our coaching. PLEASE mention disabilities, learning needs, physical impairment(s), medication, bad back or knees, etc. and/or suggest methods of working with your child. This information does not affect circus eligibility.

IMPORTANT: We will try to schedule your rehearsals around your needs if you tell us, but there are no guarantees. All rehearsals are mandatory. Everyone will have a few late night rehearsals. You may list a maximum of 3 obligations during our stay for us to try to work around.

Date (e.g.: Aug 5, 2001)	Start Time	End Time	Reason

Shipping Address (used to ship souvenirs)

Line 1⁽*⁾

Line 2

City *⁽⁾**	State	Zip *⁽⁾**	Country

Home Phone ⁽*⁾

Parents' Names ⁽*⁾

Dad's Cell

and/or

Mom's Cell ⁽*⁾

Dad's E-mail

and/or

Mom's E-mail ⁽*⁾

In case of emergency, who else can we contact?
Name *⁽⁾**	Relationship *⁽⁾**	Phone *⁽⁾**

This remainder of this form must be COMPLETED AND CHECKED to be accepted. By submitting this form you:

Reserve a spot for your child
ren
at the circus audition.
Assure us that all information provided on this form is correct & complete, including medical & physical restrictions.
Release your child
's
ren's
picture
s
for CIRCUS OF THE KIDS publicity (including video and the internet).
Have read, fully understand and agree to the terms of the CIRCUS OF THE KIDS PARTICIPATION CONTRACT.
Authorize medical treatment for your child
ren
if we feel it necessary & we are unable to contact you.
Indicate that you are aware that there is a risk exposure & you believe the benefits to your child
ren
outweigh the risk.

Therefore, should it become necessary for US (CIRCUS OF THE KIDS, its instructors or employees) to incur attorney’s fees & cost regarding your child

participation, you agree to pay OUR reasonable costs & attorney’s fees if WE are not held liable for injury & damages.

PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK

In consideration of the services of CIRCUS OF THE KIDS, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as "COTK"), I hereby agree to release, indemnify, and discharge COTK, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

I acknowledge that my participation in a circus arts training and instruction, including aerial arts, acrobatics, balancing and other various disciplines entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

The risks include, among other things: slips and falls; falling from equipment; rope burns; pinches, scrapes, twists and jolts that could result in scratches, bruises, sprains, lacerations, fractures, concussions, or even more severe life threatening hazards; strains, cuts, bruises, muscle soreness and fractures; musculoskeletal injuries including head, neck, and back; injuries to internal organs; the negligence of other people; my own physical condition; and the risk of emotional and psychological injuries or physical damage associated with this activity. Traveling to and from shows, meets and exhibitions raises the possibility of any manner of transportation accidents. In any event, if your child is injured, your child may require medical assistance, at your own expense.

Furthermore, COTK employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant's fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.
I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless COTK from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of COTK's equipment or facilities, including any such claims which allege negligent acts or omissions of COTK.
Should COTK or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.
In the event that I file a lawsuit against COTK, I agree to do so solely in the state of Florida, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against COTK on the basis of any claim from which I have released them herein.

I do not agree with the
terms of this agreement nor of
the Participation Contract ⁽*⁾

I have had sufficient opportunity to
read this entire document. I have
read and understood it, and I agree
to be bound by its terms, and those
of the Participation Contract ⁽*⁾

Address ⁽*⁾

Phone ⁽*⁾

Participant Signature ⁽*⁾

This signature must be that of the individual "signing" this document electronically or be made with the full knowledge and permission of the individual, otherwise it constitutes forgery under s.831.06, Florida Statutes. The individual "signing" this document affirms that the facts stated herein are true.

PARENT'S OR GUARDIAN'S ADDITIONAL INDEMNIFICATION
(Must be completed for participants under the age of 18)

In consideration of ("Minor") being permitted by COTK to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless COTK from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.

Parent/Legal Guardian Name ⁽*⁾

Address ⁽*⁾

Home Phone ⁽*⁾

Work Phone

Health Insurance Provider ⁽*⁾

Parent/Legal Guardian Signature ⁽*⁾

Please help
COTK by
donating today

Registration is now open for:

Houston, TX
ERJCC of Houston

Columbus, OH
JCC of Greater Columbus

Birmingham, AL
Levite JCC

Westport, CT
Camp Gan Israel - Westport

Wilmington, DE
Brandywine YMCA

Palm Beach Gardens, FL
JCC of the Greater Palm Beaches

Charleston, SC
Charleston Jewish Community Center

Wynnewood, PA
Kaiserman JCC

Pittsburgh, PA
JCC of Greater Pittsburgh

Tickets are now available for:

Houston, TX
ERJCC of Houston

Columbus, OH
JCC of Greater Columbus

Birmingham, AL
Levite JCC