Student FIRST Name (1) _____________________   (2) ________________________  (3) __________________________

 

Mother's (or Guardians) Name ___________________________________________________________________________

 

Father's (or Guardians) Name ___________________________________________________________________________

 

Street Address _______________________________________________________________________________________

 

City _____________________________________________________________________  Zip Code ___________________

 

Home Phone Number ___________________________________ Work Phone Number_______________________________

 

Email________________________________________________________________________________________________

 

Class Registered for ___________________________ Class Day ___________________  Class Time __________________

 

How Did You Hear About Us:          a) word of mouth         b) website         c ) other _________________________________

 

 

Mother's Cell Phone __________________________________  Father's Cell Phone _________________________________

 

Emergency Contact Name __________________________________________ Phone Number ________________________

 

Family Physician __________________________________________________  Phone Number _______________________

 

Pre-existing Medical Conditions (e.g. allergies or chronic illnesses) _______________________________________________

_____________________________________________________________________________________________________

I authorize ANN ARBOR GYMNASTICS,  LLC (dba CHAMPION GYMNASTICS) to use photography, video and audio recording of my child(ren) in the promotion of their gymnastics center. I understand that said images and/or voice would be used for advertising and promotional purposes in all conventional and electronic media, including but not limited to the Internet, print, radio or TV.

                                                          ______ YES                                      _____ NO

_______________________________________________________________________________________________________

I hereby give my permission for the above named student (s) to participate in any and all activities at ANN ARBOR GYMNASTICS, LLC (dba CHAMPION GYMNASTICS)

Further, I authorize ANN ARBOR GYMNASTICS, LLC (dba CHAMPION GYMNASTICS) to provide emergency treatment of an injury to or illness of my child if qualified medical personnel consider treatment necessary and perform the treatment.  This authorization is granted only if I cannot be reached and a reasonable effort has been made to do so.  

My child and I are aware that participating in the activity mentioned above is a potentially hazardous activity. I assume all risks associated with participation in this sport, including but not limited to falls, contact with other participants, the effects of the weather, traffic, and other reasonable risks conditions associated with the sport.  All such risks to my child are known and understood by me.