2019 CHRISTMAS TRAINING REGISTRATION Please fill out the form below to sign-up for the 2019 Christmas Training Session. Locations: • Madison, MS - Madison Central High School football field and weight room (1417 Highland Colony Parkway, Madison, MS 39110) • Flowood, MS - University Wellness Center (2625 Courthouse Circle, Flowood, MS 39232) • Biloxi, MS - St. Patrick Catholic High School football field and weight room (18300 St. Patrick Road, Biloxi, MS 39532) • Pascagoula, MS - Pascagoula High School football field and weight room (1716 Tucker Avenue, Pascagoula, MS 39567) • Greenville, MS - The Hodding Carter Memorial YMCA (1688 Fairground Road, Greenville, MS 38703) Dates: Monday, December 2, 2019 - Thursday, December 19, 2019 Training Days: Monday - Thursday (4 days per week)Location: Madison Central High School football field and weight room (1417 Highland Colony Parkway, Madison, MS 39110) Dates: Monday, December 2, 2019 - Thursday, December 19, 2019 Training Days: Monday - Thursday (4 days per week)Location: University Wellness Center (2625 Courthouse Circle, Flowood, MS 39232) Dates: Monday, December 2, 2019 - Thursday, December 19, 2019 Training Days: Monday - Thursday (4 days per week)Location: St. Patrick Catholic High School football field and weight room (18300 St. Patrick Road, Biloxi, MS 39532) Dates: Monday, December 2, 2019 - Thursday, December 19, 2019 Training Days: Monday - Thursday (4 days per week)Location: Pascagoula High School football field and weight room (1716 Tucker Avenue, Pascagoula, MS 39567) Dates: Monday, December 2, 2019 - Thursday, December 19, 2019 Training Days: Monday - Thursday (4 days per week)Location: The Hodding Carter Memorial YMCA (1688 Fairground Road, Greenville, MS 38703) Dates: Monday, December 2, 2019 - Thursday, December 19, 2019 Training Days: Monday - Thursday (4 days per week)Cost: $250.00Early Bird Special Pricing: $155.00 The early bird special pricing ends Monday, November 25, 2019 at 11:59 p.m. Paul Lacoste Sports, Inc. must have registration, waiver, and full payment on or before Monday, November 25, 2019 at 11:59 p.m. in order for an individual to receive the early bird discount. ***If an individual chooses to mail his/her registration, waiver, and payment, the mailing envelope needs to be postmarked on or before Monday, November 25, 2019. If it is not postmarked on or before Monday, November 25, 2019, that individual will not receive the early bird discount.*** Price after early bird deadline: $250.00 Training Location*Madison, MS - Madison Central High School football field and weight room (1417 Highland Colony Parkway, Madison, MS 39110)Flowood, MS - University Wellness Center (2625 Courthouse Circle, Flowood, MS 39232)Biloxi, MS - St. Patrick Catholic High School football field and weight room (18300 St. Patrick Road, Biloxi, MS 39532)Pascagoula, MS - Pascagoula High School football field and weight room (1716 Tucker Avenue, Pascagoula, MS 39567)Greenville, MS - The Hodding Center Memorial YMCA (1688 Fairground Rd., Greenville, MS 38703)Schedule Selection*Session 1: 5:00 a.m. - 6:00 a.m.Schedule Selection*Session 1: 5:30 a.m. - 6:30 a.m.Fitness Training Form*First time clientRepeat clientAre you an employee of Margaritaville Resort Biloxi, Centennial Plaza, or White House Hotel/Cora's Restaurant?*YesNoPayment OptionsIn order to keep paperwork and payments organized, please choose one of the following payment methods: Payment Options*Full payment - Online via Paypal*Full payment - Online via Credit Card*Paul Lacoste Sports provides secure online payment. NOTE: Early Bird Special Pricing for the Christmas Session will be $155.00 . *Paul Lacoste Sports provides secure online payment. Note Standard Pricing for the Christmas Session will be $250.00 Participant InformationName* First Last Birthday* Date Format: MM slash DD slash YYYY Age*Please enter a number from 0 to 100.Gender*MFT-Shirt Size*SMLXL2XL3XL4XLContact InformationHome PhoneCell Phone*Email* Enter Email Confirm Email 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 Emergency Contact InformationEmergency Contact Name* First Last Emergency Contact Relation*Emergency Contact Cell Phone*Update Health Information*Have any health or medical issues changed since your last Paul Lacoste Sports training?YesNoHealth InformationCurrent Health Rating*Choose OneNo Health IssuesMinor Health IssuesModerate Health IssuesMajor Health IssuesCurrent Fitness Rating*Choose OneExtremely FitVery FitModerately FitUnfitMedical / Surgical History*Performance / Fitness Goals*Waiver Waiver & Release of Liability In consideration for the rights and privileges associated with my "participation in athletic strength and agility training by Paul Lacoste Sports, Inc." I acknowledge and agree to be bound by the following: Physical Ability. I understand that I will be participating in athletic strength and agility training under the guidance of Paul Lacoste Sports, Inc. I declare that I have been examined by a licensed medical physician prior to my participation in the Activity and I am aware of no physical limitations or adverse health risks associated with my participation in the Activity other than that shown in the space below. I also declare that if I later become aware of any physical limitation or adverse health risks associated with my participation in the Activity, I will immediately cease participation and notify Paul Lacoste Sports, Inc. of said condition. Assumption of the Risks. I agree that I am responsible for my safety while participating in the Activity and that such responsibility includes participating in the Activity only when I am both physically and psychologically prepared to participate safely. I ASSUME ALL RISKS CONNECTED WITH RESPONSIBILITY FOR ANY INJURY OR LOSS CONNECTED WITH MY PARTICIPATION IN THE ACTIVITY. Waiver. Aware of the risks and willing to assume them, I hereby WAIVE, RELEASE, AND HOLD HARMLESS Paul Lacoste Sports, Inc. and each of this organization\'s members, employees, agents, coaches, trainers, volunteers, doctors, event organizers or sponsors, if any ("Releasees") from all claims by me for any liability, injury, loss or damage in any way connected with my participation in the Activity, except where caused by the gross negligence or willful or wanton misconduct of any of the Releasees. I intend for this Waiver and Release to also apply to any spouse, relatives, personal representatives, heirs, beneficiaries, next of kin or assigns who might pursue any legal action or claim on my behalf. Insurance. I understand that it is my sole responsibility to maintain adequate medical insurance and understand that Paul Lacoste Sports, Inc. is not responsible for and will not be providing this coverage for me. Acknowledgement of Risks. I understand that participation in any athletic activity or other vigorous exercise, including but not limited to preparation for and participating in athletic strength and agility training ("the Activity"), involves risks of serious injury, including permanent disability, death, and other losses, both to me and my property. I understand that these injuries and losses might result not only from my actions, but from the actions, inactions or negligence of others. Use of Photographs and/or Videos Containing My Likeness. I understand that throughout my participation in the Activity, photographs and/or videos will be taken which may include myself engaging in the performance of the Activity. I hereby authorize any such photograph(s) and/or video(s) to be used by Paul Lacoste Sports, Inc. for any lawful purpose including, but not limited to, marketing, sales and merchandising. Acknowledgement of Limited Space. I understand and acknowledge that each event conducted by Paul Lacoste Sports, Inc. is limited to a specific number of participants in order to enhance each participant\'s overall experience. By signing up for this event I am occupying a space that could have been sold to another participant. I am therefore committed to paying for my space in full regardless of whether or not I complete the training. No circumstance, including but not limited to, injury, fatigue, and/or scheduling conflicts, will release me from my commitment to pay for my space. Payment for my space is non-refundable and my space is non-transferable. PHYSICAL LIMITATIONS OR ADVERSE HEALTH RISKSAcceptance of Waiver & Release of Liability* By checking this "Accept" box, I am indicating that I understand the above terms and conditions and that I intend to be fully bound by the terms stated therein. Parent InformationParent Name* First Last Parent Email* Enter Email Confirm Email Parent Cell Phone*Parent Home PhoneParent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Waiver & Release of Liability In consideration for the rights and privileges associated with my "participation in athletic strength and agility training by Paul Lacoste Sports, Inc." I acknowledge and agree to be bound by the following: Physical Ability. I understand that I will be participating in athletic strength and agility training under the guidance of Paul Lacoste Sports, Inc. I declare that I have been examined by a licensed medical physician prior to my participation in the Activity and I am aware of no physical limitations or adverse health risks associated with my participation in the Activity other than that shown in the space below. I also declare that if I later become aware of any physical limitation or adverse health risks associated with my participation in the Activity, I will immediately cease participation and notify Paul Lacoste Sports, Inc. of said condition. Assumption of the Risks. I agree that I am responsible for my safety while participating in the Activity and that such responsibility includes participating in the Activity only when I am both physically and psychologically prepared to participate safely. I ASSUME ALL RISKS CONNECTED WITH RESPONSIBILITY FOR ANY INJURY OR LOSS CONNECTED WITH MY PARTICIPATION IN THE ACTIVITY. Waiver. Aware of the risks and willing to assume them, I hereby WAIVE, RELEASE, AND HOLD HARMLESS Paul Lacoste Sports, Inc. and each of this organization\'s members, employees, agents, coaches, trainers, volunteers, doctors, event organizers or sponsors, if any ("Releasees") from all claims by me for any liability, injury, loss or damage in any way connected with my participation in the Activity, except where caused by the gross negligence or willful or wanton misconduct of any of the Releasees. I intend for this Waiver and Release to also apply to any spouse, relatives, personal representatives, heirs, beneficiaries, next of kin or assigns who might pursue any legal action or claim on my behalf. Insurance. I understand that it is my sole responsibility to maintain adequate medical insurance and understand that Paul Lacoste Sports, Inc. is not responsible for and will not be providing this coverage for me. Acknowledgement of Risks. I understand that participation in any athletic activity or other vigorous exercise, including but not limited to preparation for and participating in athletic strength and agility training ("the Activity"), involves risks of serious injury, including permanent disability, death, and other losses, both to me and my property. I understand that these injuries and losses might result not only from my actions, but from the actions, inactions or negligence of others. Use of Photographs and/or Videos Containing My Likeness. I understand that throughout my participation in the Activity, photographs and/or videos will be taken which may include myself engaging in the performance of the Activity. I hereby authorize any such photograph(s) and/or video(s) to be used by Paul Lacoste Sports, Inc. for any lawful purpose including, but not limited to, marketing, sales and merchandising. Acknowledgement of Limited Space. I understand and acknowledge that each event conducted by Paul Lacoste Sports, Inc. is limited to a specific number of participants in order to enhance each participant\'s overall experience. By signing up for this event I am occupying a space that could have been sold to another participant. I am therefore committed to paying for my space in full regardless of whether or not I complete the training. No circumstance, including but not limited to, injury, fatigue, and/or scheduling conflicts, will release me from my commitment to pay for my space. Payment for my space is non-refundable and my space is non-transferable. PHYSICAL LIMITATIONS OR ADVERSE HEALTH RISKSAcceptance of Waiver & Release of Liability* By checking this "Accept" box, I am indicating that I understand the above terms and conditions and that I intend to be fully bound by the terms stated therein. By clicking "Accept" I also certify that I am the Parent/Guardian of the. CAPTCHAChristmas Camp* Price: $250.00 Christmas Camp Early Bird* Price: $155.00 Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms. Useful Links About Programs Results Motivational Speaking Victory Sports Foundation Shop Contact (601) 398-0950 Paul Lacoste Sports Post Office Box 1998 Ridgeland, MS 39158 Follow Login
