The Gymnastics Revolution 6714 Camp Reg
User Manual: 6714
Open the PDF directly: View PDF 
.
Page Count: 1
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
_________________ ___________________ __________________ ________ ______
Mother’s Name Street Address City State Zip
__________ _____________ _______________ _______________ _______________
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
