Parent's Night Out Fridays from 7:00pm to 10:30pm
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone:* Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Emergency Contact Info
Students entered below will be added to your family's account
Will you be picking up your child?*
If no, who will be picking up your child?
Does your child have any allergies? If yes, please state below.*
Additional Information:
Appreciation of Risk:
I understand that my child will be eating pizza & snacks, drinking Icee and participating in various gymnastics related activities.

By the very nature of the activity, gymnastics carries a risk of physical injury. No matter how careful the gymnast and coach are, no matter how many spotters used, no matter what height is used or what landing surface exists, that risk cannot be eliminated. The risk of injury includes minor injuries such as bruises and more serious injuries such as broken bones, dislocations and muscle pulls. The risk also includes catastrophic injuries such as permanent paralysis or even death from landings or falls on the back, neck or head.

I and my child are fully aware of and appreciate that gymnastics activities involve motion, rotation and height, and, therefore creates the possibility of serious injury. I agree to assume liability for all medical costs and other damages resulting from injury to my child not occasioned by gross negligence or willful misconduct of an employee of Jill's Gymnastics. Further, I agree to hold Jill's Gymnastics and it's staff harmless from any liability occasioned by any such injury.

I've read the above and agree.
Medical Release Statement:
I hereby give permission for my child to get emergency treatment if necessary, and I understand that I will pay the subsequent costs. I release and discharge any and all rights and claims against Jill's Gymnastics for any medical costs.
I've read the above and agree.
Enter your Full Name: *   
Other Questions/Comments:
Credit Card Verification:
Card Number:  
Name as it appears on card:
Card Expiration Month:   Exp Year:
Address Line 1: Address Line 2:
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