The Gymnastics Revolution 6714 Camp Reg
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The Gymnastics Revolution “Setting Children on a course for tomorrow” 6714 White Dr., West Palm Beach, FL 33407 Phone: (561)848-4577 Fax: (561)848-3155 Thegymnasticsrevolution.com Camp Registration Form 2011/2012 ________________________ __________ _____ ______ _______________________ 1st Child’s Full Name Sex Age DOB School Name & grade ________________________ __________ _____ ______ _______________________ 2nd Child’s Full Name Sex Age DOB School Name & grade _________________ ___________________ __________________ ________ ______ Street Address City State Zip Mother’s Name __________ _____________ _______________ _______________ _______________ Home Phone Work Phone Mobile Phone ** E-Mail Occupation _________________ ___________________ __________________ ________ ______ Father’s Name Street Address City State Zip __________ _____________ _______________ _______________ _______________ Home Phone Work Phone Mobile Phone ** E-Mail Occupation Emergency Contact:__________________________Phone_______________________ Relationship to student__________________________________ Physicians name_______________________________________Phone______________ Student(s) Medical Insurance Provider:_____________________________________________ Medical conditions/allergies:_______________________________________________________________ Member Enrollment Information Read before signing! Acknowledgement of Policies, Risk and Waiver of Liability I recognize that potentially severe injuries, including but not limited to permanent paralysis or death can occur in sports or activities involving height or motion, including but not limited to gymnastics, tumbling, trampoline, cheerleading, dance, ball sports, and martial arts. Being fully aware of these dangers, I voluntarily consent for my child/children to participate in all The Gymnastics Revolution programs and accept all risks associated with that participation. In consideration for allowing my child to use these facilities, I on my own behalf and the behalf of my child and our respective heirs, administrators, executors and successors, hereby forever release and covenant not to sue The Gymnastics Revolution, its officers, directors, share holders, employees, volunteers, and all others associated with the LLC from all liability for any and all damages and injuries suffered by my child or myself while under all instruction, supervision or control of The Gymnastics Revolution. I hereby agree to individually provide for all present and possible future medical expenses which may be incurred by my child as a result of any injury sustained while participating at or for The Gymnastics Revolution. I understand that The Gymnastics Revolution retains the rights to use any photographs, videotapes, motion picture recordings, or any other record of events for publicity, advertising, or any legitimate purposes. The Gymnastics Revolution reserves the right to cancel classes that do not have sufficient enrollment and transfer students. Additionally, I understand and agree to abide by the make-up policy. I have read and understand this acknowledgment of policies, risk and waiver of liability and I voluntarily affix my name in agreement. __________________________________________________ Parent Signature/ Date
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