Today's
Date__________________
1st
Child Name ______________________________ Birthdate_____________ Age______
Class
Name/Day/Time ____________________________ Class Tuition____________
Registration
Fee _________
2nd
Child Name ______________________________ Birthdate_____________ Age______
Class
Name/Day/Time ____________________________ Class Tuition____________
Registration
Fee _________
3rd
Child Name ______________________________ Birthdate_____________ Age______
Class
Name/Day/Time ____________________________ Class Tuition____________
Registration
Fee _________
Mothers Name
_________________________________Occupation_______________________
Fathers Name _________________________________Occupation_______________________
Address
_______________________________________City_________________ Zip________
Home Phone
______________________________ Work Phone______________________
Cell Phone
________________________________ Pager __________________________
How did you find
out about SPLITZ Gymnastics?______________________________________
I fully understand
that the staff at SPLITZ Gymnastics Academy, Inc. are
not physicians or medical practitioners of any kind. With that in mind, I hereby release
If we are unable
to contact the parents the person to contact in case of an emergency is:
Name/Relationship___________________________________ Phone
_____________________
Does your child/children have any medical
conditions that we should be aware of?
___________________________________________________________________
Signature of
Parent/Guardian _____________________________________________________
Please
read the policies below carefully. Your
signature below acknowledges you have read and understood them.
Child's Safety - I understand I am
responsible for my child's behavior and safety while on the SPLITZ Gymnastics
premises … including parking lots, bathrooms, waiting areas, lounge area, ect. I am also responsible for my child's behavior
during class. I understand that if my
child does not follow the instructors directions they
may be removed from class at the instructors discretion.
Tuition - I understand that tuition
is due in full at the time of registration for each session. I understand that no refunds will be made
after the first class. Refunds before
the first class will be charged a $10.00 processing fee. I know there will be a $20.00 charge for all
returned NSF checks.
My
child will not be allowed to take classes if my account is past due.
Missed Classes - I realize that no credit
is ever given for missed classes. Missed
classes can be made up on a space available limited basis. I know I must schedule any make-up classes
with the office. Any scheduled make-up class cannot be rescheduled. All missed classes must be made up within 30
days and I am allowed only one make-up class every 30 days.
Registration Fee - A $30.00 registration fee
is payable once a year from the date of enrollment. Each additional child will have a $10.00
yearly fee. I also have the choice of
paying a $10.00 per session fee.
Canceled Classes - I understand
_______________________________________________________________ _________________
Parent
/ Guardian Signature Date
RELEASE OF LIABILITY, WAIVER OF LIABILITY
ASSUMPTION OF FULL RESPONSIBILITY OF ALL RISKS OF
BODILY INJURY OR DAMAGES
As a parent or legal guardian of
_________________________________________________
I
give my consent for him/her to participate in the programs at SPLITZ Gymnastics
Academy, Inc. I understand that
participation in gymnastics, trampoline, dance, and related activities may
result in unavoidable injuries due to the heights and motions involved. These injuries may include muscle strains and
tears, broken bones, and severe injuries such as permanent paralysis or even
death. I am fully aware of the risks and
possibility of injury involved.
As a parent or legal guardian, I agree to provide
health insurance for the minor child or guarantee payment of any medical
expenses incurred as a result of training, performing, or participating in
activities of SPLITZ Gymnastics Academy, Inc.
I understand it is this gym's intent to provide for
the safety and protection of my child and in consideration for allowing the
above named minor child to participate
in activities with SPLITZ Gymnastics Academy, Inc., I waive any and all rights
or causes of action against Eileen Spicher and/or
Greg Spicher and/or SPLITZ Gymnastics Academy, Inc.
for any injuries suffered by my child and other damages suffered by my child or
myself while under the supervision or control of SPLITZ Gymnastics Academy,
Inc. and it's employees and/or the SPLITZ booster club.
This acknowledgment of risk and WAIVER OF LIABILITY
has been read by me and understood completely and signed voluntarily. I am 18 years of age or older. This agreement will remain in effect until
written revocation is received.
_______________________________________________________________ _________________
Parent
/ Guardian Signature
Date