Student’s Full Name: ________________________________________________ Date of Birth: ___________

Male or Female: ________ Registration Date: ______________ Home Phone: ________________________

Mother’s Name: __________________________ Father’s Name: ____________________________________

Mother’s Work Phone: ________________________ Father’s Work Phone: ____________________________

Billing Address: _________________________________ City: __________________ Zip: ________________

Person to be Billed: ____Mother ____Father ____Other: ___________________________________________

Another Name & Phone for Emergencies: _______________________________________________________

Does your child have any medical problems we should be aware of? List any and all allergies or sensitivities to drugs,
medicine, or bites:
_________________________________________________________________________________________

I, We, the undersigned parent(s) of __________________________________, a minor, do hereby authorize any adult instructor of GYMTOWNE GYMNASTICS as agent(s) for the undersigned to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of the said physician or at the hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

This authorization shall remain effective indefinitely, unless sooner revoked in writing, and delivered to said agent(s).

I, We, are aware that participation in gymnastics activities can result in serious injury and even death in rare cases. Those individuals attending the gym and using the facilities, do so at their own risk. The gym operator shall not be liable for any damage arising from personal injuries sustained by the participant in or about the premises and the participant and parents (if minor) does hereby fully release and discharge the gym operator, all associated gyms, their owners, employees, and agents from all claims, demands, rights of action, present or future, resulting from or arising out of the participant’s use of the gym and/or its facilities.

I have read and understand the rules and policies of GYMTOWNE GYMNASTICS and agree to abide by them. I also understand that I am responsible to pay for classes until the date I notify the GYMTOWNE GYMNASTICS OFFICE IN WRITING of my intention to terminate.
_________________________________ ___________________________________ _________________
            DOCTOR’S NAME                                  PARENT’S SIGNATURE                         DATE