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First Name:______________________ Middle: ______________________ Last:___________________ Street:_________________________________ Apt #:____City:___________________ Zip:__________ The above address belongs to: Parents ___ Mother ___ Father ___ Other ____________ Date of birth:___/___/___ Age:___ Grade during 2010-2011 school year:_______________ Mother’s Name:________________________ Home Phone:_____________ Cell:_______________ Father’s Name:_________________________ Home Phone:_____________ Cell:_______________ If the above child lives with a legal guardian (other than parents) please fill below. Name:_____________________ Relation:________________ Home:____________ Cell:___________ Emergency Contact: (Please list someone other than parents) Name:_____________________ Relation:________________ Home:____________ Cell:___________ Please list any medical conditions, or concerns, that may affect your child’s participation, as well any medications your child may be taking: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 1st Class: ___________________________ Day & Time:_________________ Class Fee: $______ 2nd Class: ___________________________ Day & Time:_________________ Class Fee: $______ 2010-2011 Registration Fee: $30.00 THIS FOLLOWING STATEMENT MUST BE READ BEFORE SIGNING Total: $______ I fully understand that C. Natalie Stanley’s Tumble Town Gymnastics, Inc., hitherto, CNSTTG, staff members are not physicians or medical practitioners of any kind. With the above in mind, I hereby release CNSTTG’s staff to render temporary first aid to my child, or children, in the event of any injury or illness, and if deemed necessary, by CNSTTG’s staff to call our doctor, and to seek medical help, including transportation by a CNSTTG staff member, and or its’ representatives, whether paid or volunteer, to any health care facility or hospital, or the calling of an ambulance for said child should the CNSTTG staff deem it necessary. We, the staff of CNSTTG recognize our obligation to make our students and their parents aware of the risks and hazards associated with the sport of gymnastics, tumbling, cheerleading and dance. Students may suffer injuries, possibly minor, serious, or catastrophic in nature. Gymnastics, tumbling and cheerleading can be dangerous and lead to injury! Parents should make their children aware of the possibility of injury and encourage their children to follow all the safety rules and coaches instructions. The CNSTTG, its’ coaches and other staff members, will not accept responsibility for injuries sustained by any student during the course of gymnastics, tumbling, dance or cheerleading instruction, open workouts, in the course of any exhibition, competition, camp, event or clinic in which he or she may participate or while traveling to or from the event. With the above in mind, and being fully aware of the risk and possibility of injury involved, I consent to have my children or children participate in the programs offered by CNSTTG and or its representatives whether paid or volunteer. I also affirm that I now have and will continue to provide proper hospitalization, health and accident insurance coverage which I consider adequate for both my child’s protection and my own. I also understand that it is the parents or legal guardian’s responsibility to warn the child about the dangers of injury. The parent should warn the child according to what the parent feels is appropriate. CNSTTG will only warn the child through “Safety Message” and our teaching style and progressions. By signing this, you agree to the above, our payment policies for the time period your child participates in our program offerings. Parent or Legal Guardian Signature:__________________________________Date:____________ MUST BE SIGNED BEFORE PARTICIPATION WITHOUT EXCEPTION
IF YOU WANT TO SIGN UP FOR AUTOMATIC WITHDRAW, AND SAVE $5.00 EVERY MONTH OFF OF CLASS TUITION, FILL IN THE FOLLOWING INFORMATION.
Nine digit routing number: ___ ___ ___ ___ ___ ___ ___ ___ ___ Checking account number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
from my bank account for the time period I specify ————>______________________Signature
For current student who already have a voided check on file, just sign in the box and return the form. Those paying for classes by automatic withdraw, need only enclose a voided check. All others enclose full payment for class and registration fees for 2010-11 participation. |
