Registration
REACH Homeschool Open Gym --Socks are not allowed in the gym --There are no additional fees for credit or debit card payments.
Event:
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Type*
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
 
Address: *
City: * State: * Zip: *
Emergency Contact/Others allowed to pick up*
 
 
Students entered below will be added to your family's account
 
Questions/Options:
PAC requires that all participants carry primary insurance. Every child is covered by a secondary insurance program with a $100.00 deductible. Print name of insurance company:*
 
Additional Information:
 
Waiver
General Release:
In consideration of participating in the activities of Palmetto Athletic Center, I represent that I understand the nature of this Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue participation in the activity. I fully understand that this Activity involves risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the "releasees" named below; and that there maybe be other risks either not known to me or not readily foreseeable at this time;and I fully accept and assume all such risks and all responsibility for losses, cost, and damages I incur as a result of my participation in the Activity.
I hereby release, discharge, and covenant not to sue Palmetto Athletic Center, its respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners, and lessors of premises on which the Activity takes place,(each considered one of the "releasees" herein) from all liability, claims, demands, losses, or damages, on my account caused or alleged to be caused in whole or in part by the negligence of the "releasees" or otherwise, including negligent rescue operations and future agree that if, despite this release, waiver of liability, and assumption of risk I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost, which any may incur as the result of such claim.
I have read the Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.
Medical attention: I hereby give my consent to PAC and/or the Host Organization to provide, through a medical staff of its choice, customary medical/athletic training attention, transportation, and emergency medical services as warranted in the course of my child’s participation.

Parental Consent
And I, the minor's parent and/or legal guardian, understand the nature of the above referenced activities and the Minor's experience and capabilities and believe the minor to be qualified to participate in such activity. I hereby Release, discharge, covenant not to sue and AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS each of the releasees for all liability, claims, demands, losses or damages on the minor's account caused or alleged to have been caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations and further agree that if, despite this release, I, the minor, or anyone on the minor's behalf makes a claim against any of the above Releasees, I WILL INDEMNIFY,SAVE AND HOLD HARMLESS each of the Releasees from any litigation expenses, attorney fees, loss liability, damage, or cost of any Releasee my incur as the result of any such claim.

I've read the above and agree.
 
Payment
I understand that my credit card on file will be processed for the total amount.
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: *
Nickname:
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*