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Registration Form


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icon06/01/2009 - Registration Form

Student's Name:
Last Name:
Birthdate:
Boy or Girl:
Class Name Or Camp:
Day(s) or Dates:
Time:
Home Address:
City:
Zip Code:
Home Phone:
Email Address:
Mother's Name
Mother's Last Name:
Cell Phone:
Work Phone:
Father's Name:
Cell Phone:
Work Phone:
Emergency Contact:
Emergency Contact Phone:
Allergies:
Medications:
Medical Condition:

Waiver and Release:

I, the minor's parent and/or legal guardian, understand the nature of these activities and the minor's experience and capabilities and believe the minor to be qualified, in good health, and in proper physical condition to participate in such activity.

I hereby release, discharge, covenant not to sue, and agree to indemnify and save and hold harmless Xtreme Gymnastics from all liability claims, demands, losses, or damages on the minor's account caused or alleged to be caused or alleged to be caused, in whole or in part by the negligence of Xtreme Gymnastics or otherwise, including negligent rescue operations.

 

 I further agree that if despite this release, I the minor, or anyone on the minor's behalf, makes a claim against Xtreme Gymnastics its owners, operators, coaches and other members, I will indemnify, save and hold harmless each of the releasees from any litigation expenses, attorney fees, loss liability, damage, or cost any may incur as the result of any such claim.  I further agree to not drop my child off nor pick my child up, more than 15 minutes before or after his/her scheduled class. I hereby grant Xtreme Gymnastics permission to use photographs and other images of my child/children for Xtreme Gymnastics’ promotional materials.

Medical Release: I hereby give my consent to Xtreme Gymnastics to provide emergency care and to give authority to any hospital or doctor to render immediate aide as might be required at the time for my child's health and safety.

CONCUSSION AWARENESS:  A forceful bump, blow or jolt to the head or body may cause a concussion. Symptoms may be immediate but can also take hours to appear. If you suspect that your child has a concussion…take him/her out of play and seek the advice of a health care professional experienced in evaluation for concussion. For more information, visit www.cdc.gov/Concussion


 

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