EXTREME ACTION POWER TUMBLING ACADEMY

PERMISSION/REGISTRATION FORM

Mother's Name: Employer: Cell#______

Father’s Name: Employer:______Cell#______

Address: City: Zip: ______

Home Phone: ______Alt. Phone: ______

Person Responsible for Account Payment ______School: ______

Parent email address: Please include for current info & updates

Payment method:______

Childs First and Last Name / Boy/Girl / Birth Date
00/00/00 / Day / Time / Class Type / Level / Amount
Medical Concerns: / Discount
Total

I/We the undersigned, in entering the Extreme Action Power Tumbling Academy LLC, are aware of the risks of personal injury involved in power tumbling, double-mini trampoline, trampoline, cheerleading, and sports skills which could be: serious broken bones and catastrophic injury causing permanent paralysis or even death. In consideration of being allowed to this organization, I/we hereby release Extreme Action Power Tumbling Academy LLC, and it's affiliated employees, and building owners from all liability for any and all damages and injuries suffered by myself or by my child in connection with the use of facilities in subject or while on these premises. I understand that participation is entirely by my own choice and agree to accede to any question or decision made by Extreme Action Power Tumbling Academy or it's employees. Additionally, although there may be other playroom areas available for the convenience of the Extreme Action Power Tumbling Academy's patrons and their children, there is no child-care provided or other similar supervision. Each party that utilizes the playroom areas does so acknowledging the above and assumes all the risks and responsibilities thereof. I understand that a monthly finance charge of $10.00 will be applied to all unpaid accounts on the 10th of the month and a 33% Collection Fees incurred will be paid by the undersigned if this account goes to collections. I have read the Academy’s Rules and Policies.

Parent or Guardian (Please Print) (Please Sign)

Date Signed: ______

CONSENT TO TREATMENT AND STUDENT INFORMATION

Fill out the information below so we may act quickly in the event of an accident.

I/We the undersigned parents of a minor, do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered to said minor(s) in case of accident and or illness that may occur while in the company of EXTREME ACTION POWER TUMBLING ACADEMY, and it's employees. It is understood that this consent is given in advance of any specific diagnosis or treatment being required.

DOCTOR'S NAME: PHONE:

MEDICAL INSURANCE CO: POLICY #:______

NAME OF POLICY HOLDER:

CONSENT TO PHOTOGRAPH: ______
(Parents signature) (Date)
In the event that we would like to use a picture in advertising, on our website or any other related materials. Names will be used only with written permission from parent or guardian.

REGISTRATION RENEWAL DATE: SEPTEMBER OF NEXT YEAR

Date Enrolled: / / Registration Fee $30.00 PD Check Number______

Inactive Date: Reason:______

Revised: 09/08/05 regform08-05.mwd