Registration Information & Parental Emergency Medical Consent

This form must be presented upon admission for treatment

Student’s Name:Date of Birth: / / Gender: M F Phone:

How did you hear about us?School Attending:

Does anyone in the household have gymnastics experience?

Parents/Guardians/Custodians with whom the Child resides:

Mother/ Guardians:Cell Phone:

Address:City: Zip:

Employer:Work Phone:

Father/ Guardians:Cell Phone:

Address:City: Zip:

Employer:Work Phone:

Persons to Contact if above are unavailable, and are Authorized to Pick up Child:

Name:Relationship to Child:

Address:Home Phone:

Work phone:Cell Phone:

Name:Relationship to Child:

Address:Home Phone:

Work phone:Cell Phone:

Information:

Child’s Doctor:Phone:

Address:Last Tetanus:Know Allergies:

Present Medication:Medical Concerns:

Insurance CompanyPolicyholder’s ID:

(OVER)

CONSENT TO TREAT

In the event that my child (listed above) may require medical and/or surgical care while I am out of the city or unable to be reached, I hereby give my consent to medical and/or surgical treatment to Hospital and Doctor or his/her designee to provide this care. I agree to pay the entire costs and fees contingent on any emergency medical care and/or treatments for my child as secured or authorized under this consent. THIS CONSENT WILL BE IN EFFECT

BEGINNING (date) AND CONTINUING WHILE THE CHILD IS ENROLLED IN THIS FACILITY.

WARNING

Any activity involving motion or height creates the possibility of serious injury, including permanent paralysis and even death from landing or falling on the head or neck.

You assume a risk of serious injury by participating in any programs that involve motion or height.

In consideration of being permitted to participate in the C.R.A.G. Gymnastics program for recreational benefits to myself/my child, having been forewarned of the danger to myself/my child, I hereby waive and release any and all claims of damages I may have against C.R.A.G. Gymnastics, the individual members thereof and all the owners, agents, and employees, free and harmless from any loss, damage, liability, injury, negligence, cost of expense that may be suffered by me/my child while participating with or practicing for the activities of the program.

I agree that I will abide by all rules, regulations, and conditions as prescribed by C.R.A.G. Gymnastics.

AGREEMENT

I give my consent to let my child be photographed for use on the Internet or in print materials as well as other media by C.R.A.G. Gymnastics.

I give my consent in emergency situations for the person(s) in authority to seek the nearest medical care for my child.

I understand that C.R.A.G. Gymnastics is not responsible for my child before or after their instruction time. Please make sure your child is picked up on time.

PAYMENT POLICY

I understand that it is my responsibility to inform C.R.A.G. Gymnastics when my child is going to be leaving the program. Until I have done so my child will be enrolled and I will be required to continue to make my payments as they come due. (initials ____ )

Payments are due the first class of each session (dates have been provided), we do not send out bills. Any account not paid within the first week of the session will be assessed an administrative fee of $5.00. (initials ____ )

I HAVE READ THE WARNINGS, AGREEMENT, AND PAYMENT POLICIES, UNDERSTAND AND AGREE TO ABIDE BY THEM.

Parent or Guardian Signature:Date:

Parent E-mail Address:______