Please Include the Registration Fee of $40 (Annually)

Registration Form

Please include the registration fee of $40 (annually)

Date: ______

Student Name: ______Age: ______DOB: ______

Parent/Guardian: ______

Phone: ______Cell Phone: ______

Address: ______

E-mail: ______

Place of Employment: ______Phone: ______

Parent/Guardian: ______

Phone: ______Cell Phone: ______

Address: ______

E-mail: ______

Place of Employment: ______Phone: ______

Emergency Contact: ______Phone: ______

Family physician: ______Phone: ______

Family dentist: ______Phone: ______

Does your child have any allergies? If so, what are they? ______

Does your child have any special dietary needs? If so, what are they? ______

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Does your child currently take any medications? If so, what are they? ______

Does your child currently have any special needs that we should know about that would help us to better serve him/her? If so, what are they? ______

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Who other than a parent may pick the children/child up? ______

Name Phone Number

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Name Phone Number

Enrollment days/times: ______

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What is the current swimming level of your child? ______

If your child requires a car seat for travel to the Bellows Falls recreations center please leave one at Gem Starz.

If your child does not need a car seat, please sign on the line below.

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Parent Signature

LIABILITY WAIVER: As a parent/legal guardian of my designated student(s), I grant permission for this minor to participate in gymnastics and recreational events in the facility's program(s). I assume all risks and hazards incidental to participation. I do hold harmless Gem Starz, the instructors, and all other volunteers, participants, and organizers for any claims arising out of injury to my child.I recognize that potentially severe injuries can occur in any activity involving height or motion, including tumbling and related activities including cheerleading, tumble tramp, trampoline, stunting, pyramids, dance, swimming, martial arts, gymnastics and physical activity in general. I understand that it is the express intent of all staff and personnel to provide for the safety and protection of my student(s) and, in consideration for allowing my student(s) to use these facilities, I herebyCOVENANT NOT TO SUE and FOREVER RELEASEthis facility, affiliated and partner companies and organizations, property owners and lessors, staff, contractors, subcontractors, teachers, coaches, owners, directors and other members involved in this facility's program(s), from all liability and for any and all damages and injuries suffered by my student(s) during instruction, supervision, and/or control during any and all classes or extra activities.

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Parent Signature Date

MEDICAL RELEASE: I further grant permission for emergency first aid to be given to my child in the case of injury. If necessary, I grant permission for my child to be taken to the emergency room of a nearby hospital, and its staff have my authorization to provide treatment which a physician deems reasonably necessary for the wellbeing of my child.

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Parent Signature Date

MINOR CONSENT AND ASSUMPTION OF RISK STATEMENT: I will instruct my child (the minor participant) to carefully follow all gymnastics safety rules. I/We will fully understand that: (1) There are risks and dangers associated with participation in gymnastic events and recreational activities, including, but not limited to those of bodily injury, partial and/or total disability, paralysis, and death. (2) This social and economic losses and/or damages, which could result from those risks and dangers described above, could be severe. (3) These risks and danger may be caused by the negligence of the participant of the negligence of others. (4) There may be other risks not known to us or not reasonably foreseeable at this time. I/We accept and assume such risks and responsibility for the losses and/or damages following such injury, disability, paralysis, or death, however caused or alleged to be caused in whole or in part by the negligence of Gem Starz, other participants, or employees.

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Parent Signature Date

PHOTO/MEDIA RELEASE: I, hereby, grant to, Gem Starz, or any publisher, web or media entity Gem Starz enters into publishing or media agreements with permission to copyright and/or use and/or publish and republish, photographic pictures, videos and portraits of my child in which he/she may be included in whole or in part, in color or black and white, made through any media by the photographer in the gym or elsewhere, including the use of any printed matter in conjunction with such photographs.

I, hereby, waive my right to inspect and/or approve the finished photograph copy or printed matter that may be used in conjunction with such photographs, or the eventual use that might be applied.

I, hereby, release and discharge the above, its assign, and all persona acting under its permission or authority or those for whom it is acting, from and against any liability that may occur in the taking of photographs, or reproductions of the finished product.

I, hereby, consent to the use of these photographs without financial compensation.

I have read the foregoing release and warrant that I fully understand the contents thereof.

______I DO NOT WISH TO GRANT PERMISSION TO USE YOUR STUDENT(S) IMAGE.

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Parent Signature Date