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Membership Form |
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Today’s Date: _________
Student Name:_______________________________________D.O.B_______________
Address:________________________________________________________________
Street
City
Zip
Phone #:_________________________School:_________________________________
Father’s Name:__________________________________Occupation:_______________
Business Address:_________________________________Phone #:_________________
Mother’s Name:__________________________________Occupation:_______________
Business Address:_________________________________Phone #:_________________
Parent’s Email Address:____________________________________________________
Physician:________________________________________Phone #:________________
Medical Insurance Company:________________________________________________
Emergency Contact:________________________________Phone #:________________
(other than parent)
Does your child have and medical conditions that we should be aware of?
(Diabetes, asthma, heart problems, epilepsy, etc.)_____________________________________________
List any and all allergies of sensitivities to drugs,
medications, and/or bites, etc.
________________________________________________________________________
How did you first learn about Bright Stars? Who
can we thank for referring you?
_________________________________________________________________
The day, time and name of class you are registering for:______________________
____ I understand an
adult must bring my child
down into the gym and also come back
(Initial)
down into the gym to pick my child up after class.
____ I understand tuition credits will not be given for missed classes.
(Initial)
Missed classes can be made up during
open-gym. Make-up classes are not
permitted during regularly scheduled classes. Exceptions will not be
considered. Thank you for your cooperation. Open gym times will be posted. Please check our website at www.Brightstarsgym.com.
PARTICIPANT AGREEMENT, RELEASE & ACKNOWLEDGEMENT OF RISK
I/We the undersigned
parent(s) of _______________________, minor, do hereby authorize any adult
instructor of Bright Stars Gymnastics agent(s) for the undersigned, consent
to any x-ray examination, anesthetic, medical or surgical diagnosis or
treatment and hospital care which is deemed advisable by, and is rendered under
general or special supervision of any physician and surgeon licensed under the
provision of the Medicine Practice Act, whether such diagnosis or treatment is
rendered at the office of the said physician or at the hospital. It is understood that this authorization is
given in advance of any specific diagnosis, treatment, or hospital care being
required but is given to provide authority and power of the part of our
aforesaid agent(s) to give specific consent to any and all such diagnosis,
treatment, or hospital care with the aforementioned physician in the exercise
of his/her best judgment may deem advisable. The authorization shall remain
effective indefinitely, unless sooner evoked in writing, and delivered to the
said agent(s).
In consideration to the
services of Bright Stars Gymnastics, the agents, owners, owner’s officers,
employees, and all other persons or entities acting in any capacity on their
behalf, I hereby agree to release personal representative and estate as
follows:
1.
I understand and
acknowledge that the activity I am about to engage in possesses known risks and
unanticipated risks which could result in injury, paralysis, death, emotional
distress or damage to myself, to property, or to third parties. The following describes some, but not all, of
those risks. Gymnastics entails certain
risks, which simply cannot be eliminated without jeopardizing the essentials
qualities and aims of the activity.
Without a certain degree of risk, gymnastics students would not improve
their skills, and the enjoyment of the sport would be diminished. Gymnastics
exposes its participants to the usual risk of bruising and cuts. Other more serious risks also exist. Participants will
sometimes fall on the equipment and suffer sprains, fractures, and cuts. They also can suffer more serious injuries; Any activity involving height or motion can cause permanent
injury, paralysis or even death.
Traveling to and from shows, exhibitions and competitions raises the
possibitlies of any manners of transportation accidents. All medical assistance shall be at my own
expense.
2.
I expressly agree
and promise to accept and assume all of the risks existing in the activity as
outlined in section 1. My participation
in this activity is purely voluntary, no person(s) are forcing me to
participate and I elect of my own volition to participate with full knowledge
of the inherent risks involved.
3.
I hereby
voluntary release, forever discharge and agree to hold harmless and indemnify Bright
Stars Gymnastics from any and all liability, claims, demands, actions
or rights of action, which are related to, arise out of, or are in any way
connected with my participation in the activity, including those allegedly
attributable to the negligent acts or omissions of Bright Stars Gymnastics or
their staff.
4.
Should Bright
Stars Gymnastics, or anyone acting on their behalf, be required for any
reason to incur attorney’s fess and costs to enforce this agreement, I agree to
indemnify and reimburse Bright Stars Gymnastics for such fees
and costs.
5.
I certify that I
have health, accident and liability insurance to cover any bodily injury or
property damage I may cause or suffer while participation in the sport of
gymnastics, or else I agree to indemnify and reimburse Bright Stars Gymnastics for
such fees and costs incurred.
By signing this document I
acknowledge that if anyone is hurt or property is damaged during my
participation in this activity, I may be found, by a court of law, to have
waived my right to maintain a lawsuit against Bright Stars Gymnastics on the
basis of any claim from which I have released them herein. I have had sufficient opportunity to read and
fully understand this entire document and I agree to be legally bound by it terms.
Signature of Participant_________________________________Print
Name_________________________
Parent Signature if
Participant is a Minor_____________________________________________________
Date________________