Easley Gymnastics Training Center

Registration Form

                         ( Please Print)

                                  Valid Thru July:_______

Student Information

Last Name:________________  

First Name: ________________    

MI: ____

Name Student Goes By:________________ 

D.O.B.:___________  Sex:______

Billing Adress: ____________________________

          City:__________________  State:  _____

          Zip:__________

Home Phone:__________________        

Student Cell Phone: ____________

School:  _____________________________     

Grade:____________

Parent/Guardian Information:

Mother/Female Guardian:

(Relationship if not Mother):_______________

Last Name:______________________ 

First Name:______________________

MI:______

Home Phone: _________________  

Cell Phone:___________________

Employer:_________________________ 

Work Phone:_________________

Father/Male Guardian    

(Relationship if not Father):_________________

Last Name:______________________ 

First Name:______________________

MI:______

Home Phone:_________________      

Cell Phone:___________________ 

Employer:________________________ 

Work Phone;__________________

Insurance Information:       

**EACH STUDENT MUST HAVE THEIR OWN INSURANCE IN EFFECT**

Insurance Provider:______________________

Phone:___________________

Primary Insured:_________________________

Policy#:_________________

Emergency Contact Person:   

(Other Than A Parent - We Will Always Attempt To Contact Parents First)

Name:_____________________________________

Phone:_________________

  As the parent or legal guardian of the above listed

student, I hereby consent to the above named person participating in the programs offerd by Baskin &McCall, Inc. dba Easley Gymnastics Training Center. (hereafter EGTC).  I recognize that potentially severe injuries including sprains, broken bones, paralysis, or death can occur in any activity involving height or motion, including gymnastics.  I UNDERSTAND AND ACCEPT THIS RISK.  I have additionally communicated this risk to my child participant.  I also realize that my child will be performing and training on all gymnastics events and devices including the trampoline. 

     I further understand that while payment of tuition and registration fees consitiutes a part of the consideration due to EGTC for allowing my child to use the facilities and equipment at EGTC, an additional part of the consideration is this signed release form. 

     Therefore, in considration for allowing my child to use the EGTC equipment and facilities, I hereby release Baskin & McCall, Inc. its owners, officers, employees, teachers and coaches from all liability for any and all damage and injuries suffered by my child while under the instruction, supervision or control of EGTC, its owners, officers, employees, teachers or coaches.

     As the parent or legal guardian of the aforementioned person, I hereby agree to individually protect for the possible future medical expeses which may be incurred by my child as a result of any injury sustained while training at, for or under the direction of EGTC.  In addition, I confirm that my child has been examined by a physicain who has cleard them for unrestricted participation in thes activities.

     This acknowledgement of risk and waiver of liability, having been read throughly and understood completely, is voluntarily signed as to its content and intent.

Signature:_________________________________ 

Date:_______________

FOR OFFICE USE ONLY:

Registration Fee: $______________      

Cash/Check      Chk. No._____________

Classes:_____________________________      

Day:__________     Time:___________