PLEASE FILL OUT SEPARATE FORM FOR EACH GYMNAST
THIS IS A PEANUT FREE FACILITY
This is a secure web site.
Name of Gymnast:
Street:
Street (con't):
City:
State:
Zip:
Age:
Date of Birth:
Sex:
Home telephone:
Cell phone/pager #:
Contact E-Mail
Mother's Name:
Mother's work phone:
Father's Name:
Father's work phone:
Emergency contact name:
Emergency contact phone:
RETURNING GYMNAST: Has any of the above information changed? Yes No
Classes:
Important Information
Membership Fee: The non-refundable / non-transferable Summer Registration Fee for NEW students is $20.00.
Summer Deposit: A non-refundable / non-transferable Summer Deposit of $20.00 must accompany each registration application.
Payment Due: Deposit $20.00 Payment in Full
Do you wish to have your credit / debit card automatically debited? Yes No
Do you wish to receive your invoice by email? Yes No Email address:
Credit Cardholder's Address:
Name on Card
Street (cont):
State/Province:
Zip Code:
Credit Card Information:
Visa Mastercard Discover American Express
Card Number:
CVC2 Number: On back of card
Exp. Date:
Gymnastics Village 2008 Summer Program begins Wednesday June 25, 2008 and will run for 9 weeks through Tuesday August 26, 2008.
Tuition Payments are due the first class of summer. If you choose to participate in more than the minimum number of classes (8 out of 9), then payment is due at the beginning of that class. Any bank fees associated with checks returned to us by the bank will be your responsibility and will be billed to your account.
Family Discount: A 10% discount is given for any children of the same family after the first child is enrolled at the regular tuition price. This does not apply to annual membership fee or special programs that are already discounted.
Photo Release:Gymnastics Village has my permission to use any video or snapshot of my child taken during the class time. These pictures my be used for promotional purposes for Gymnastics Village.
YES NO
Medical/Developmental: It is important that Gymnastics Village be made aware of any medical or developmental situation that our gymnasts may have. If your child has a medical problem that may require continual doctor's attention or a developmental problem that is currently being treated, please advise us. It is in the best interest for all of us that this information be shared. Specific examples might be loss of hearing, heart problems, asthma, diabetes, LD, ADD, ADHD, scoliosis, arthritis, etc. Please write any pertinent information below:
Parent/Guardian Waiver and Release:I fully understand that Gymnastics Village staff members are not physicians or medical practitioners of any kind. With the above in mind, I hereby release Gymnastics Village to render temporary first aid to my child in the event of any injury or illness, and if deemed necessary, by the Gymnastics Village staff to seek medical help and/or call an ambulance. You agree that you are aware that your son/daughter will be engaging in physical exercise involving sports and fitness which could cause injury to them. Your agree that you son/daughter is voluntarily participating in these activities and is assuming all risks of injury that might result. You hereby agree to waive any claims or rights that you might incur as a result of these activities. Gymnastics Village will make no evaluation or recommendation whether your son/daughter is physically fit for any physical activity. If your son/daughter has any physical condition that may impair his/her ability to engage in the activities, it is your responsibility to obtain a physician’s statement describing any limitations to participate in this program. It is always advisable to consult a physician prior to undertaking any physical exercise program.
I have read and understand all of the policies listed above.
PLEASE LEAVE SIGNATURE BOX BLANK. STOP AT FRONT DESK TO PERSONALLY SIGN YOUR NAME.
Signature:
Date:
Gymnastics Village 13 Caldwell Drive, Amherst, NH 03031 Telephone: 603-889-8092 FAX: 603-598-4616 e-mail: judy@gymnasticsvillage.com
