Registration
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Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Father
Grandparent
Guardian
Mother
Other
Parent
Step Father
Step Mother
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
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MO
MS
MT
NE
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OR
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Zip:
*
Emergency Contact Info
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Disabilites (leave blank if none):
Allergies (leave blank if none):
Medications (leave blank if none):
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Disabilites (leave blank if none):
Allergies (leave blank if none):
Medications (leave blank if none):
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Disabilites (leave blank if none):
Allergies (leave blank if none):
Medications (leave blank if none):
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Disabilites (leave blank if none):
Allergies (leave blank if none):
Medications (leave blank if none):
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Disabilites (leave blank if none):
Allergies (leave blank if none):
Medications (leave blank if none):
Additional Information:
Acknowledgement of Risk and Waiver of Liability
(Show-Hide Details)
In consideration of my and/or my child's participation in the programs of Gymnastics Inc. dba eNeRGy Kidz, I represent that I understand the nature of this Activity and that I and or/my child is 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 concussions
(for more information about concussions click here)
, permanent disability, paralysis and death, which may be caused by my and/or my child's 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 may 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 and/or my child's participation in the Activity.
I hereby release, discharge, and covenant not to sue Gymnastics Inc. dba eNeRGy Kidz, 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 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, waiver of liability, and assumption of risk, I, the minor, or anyone on my or the minor's behalf makes a claim against any of the above Releasees, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS each of the Releases from any litigation expenses, attorney fees, loss liability, damage, or cost any Releasee may incur as the result of any 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.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
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*
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Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
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Exp Year:
*
2024
2025
2026
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2035
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2038
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2048
2049
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2051
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2053
2054
Address Line 1:
Address Line 2:
City:
State:
AK
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AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
*
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