REGISTRATION FORM

VALID THROUGH AUGUST: ________________

(PLEASE PRINT)

STUDENT INFORMATION:

LAST NAME:

FIRST:

MI:

NAME STUDENT GOES BY:

D.O.B.

SEX:

(IF NOT FIRST NAME ABOVE)

BILLING ADDRESS:

CITY:

STATE:

ZIP:

HOME PHONE:

STUDENT CELL PHONE:

SCHOOL:

GRADE:

PARENT / GUARDIAN INFORMATION:

MOTHER / FEMALE GUARDIAN:

RELATIONSHIP IF NOT MOTHER:

(CIRCLE ONE)

LAST NAME:

FIRST:

MI:

HOME PHONE:

CELL PHONE:

EMPLOYER

WORK PHONE:

FATHER / MALE GUARDIAN:

RELATIONSHIP IF NOT FATHER:

(CIRCLE ONE)

LAST NAME:

FIRST:

MI:

HOME PHONE:

CELL PHONE:

EMPLOYER

WORK PHONE:

INSURANCE INFORMATION:

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

COMPANY:

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 offered 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 constitutes 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 consideration 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 expenses 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 physician who has cleared them for unrestricted participation in these activities.

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

SIGNATURE:

DATE:

FOR OFFICE USE ONLY:

REGISTRATION FEE:

CASH / CHECK

CHECK

CLASSES:

DAY:

TIME: