Pacific Flips Online Registration

Registration

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Welcome to the Pacific Flips Online Registration page! Please provide your information below and click "submit" when done. Credit cards will NOT be charged at this time. In the comments section please indicate which gym you are interested in enrolling in. Thank you!

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

T-shirt size*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

T-shirt size*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

T-shirt size*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

T-shirt size*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

T-shirt size*

Add Another Student

Required Policies and Agreements

Tuition

Tuition is based on an average of four weeks per month. No additional charges will incur for those months with extra class days. Conversely credit will not be given for those months with less class days due to holidays or gym closures. Credit will not be given due to missed classes.

I've read the above and agree.

Payment Policies

Tuition is due on the 1st of each month. If tuition is not paid by the 10th of the month your account will be charged a $15.00 late fee and the credit card on file will be charged. We require a debit or credit card to be on file on your account.

I've read the above and agree.

Enrollment and Cancellation

Once you have registered for a class, your child will continuously remain enrolled in his or her class until you drop them by notifying the office staff IN WRITING. Withdrawal forms are available in the office. Notification must be received by the 15th of the month prior to withdrawal. There are no prorated refunds or credits for missed classes.

I've read the above and agree.

Abesence Policy

Credit will not be given due to missed classes, however make-ups can be scheduled through the office. Make-ups can be scheduled in advance in specific make-up classes or the week of the make-up in the same level class with openings. Once a make-up is scheduled it cannot be rescheduled for any reason. Students will be allowed one make-up per month. All additional make-ups need to be requested in writing and approved by the office staff.

I've read the above and agree.

Photo Release

I hereby authorize and consent to the use of my child/children's visual image by Pacific Flips for appropriate purposes, including but not limited to: still photography, videotape, electronic and print publications and websites. I give this consent with no claim for payment.

I've read the above and agree.

Assumption of Risk

In consideration of participating in the Pacific Flips gymnastics, trampoline & tumbling or cheerleading, 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 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 participation in the Activity.

I've read the above and agree.

Release of Liability

I hereby release, discharge, and covenant not to sue Pacific Flips, LLC, 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.

I've read the above and agree.

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 from 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 Releases from any litigation expenses, attorney fees, loss liability, damage, or cost any
Releasee may incur as the result of any such claim.

I've read the above and agree.

Parent Participant

This if for all adults participating in the "Mommy and Me" classes or accompanying a gymnast during Open Gym, sleep overs, special events or Birthday parties.

In consideration of participating in the gymnastics, trampoline & tumbling, or cheerleading, 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 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 participation in
the Activity.

I hereby release, discharge, and covenant not to sue Pacific Flips, LLC, 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.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*