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Class Registration Request

Student:

First Name:
Last Name:
Birth Date:
Age:
Sex:


Home Address:

Street:
City:
State:
Zip:
Home Phone:
Preferred Email Address:

Parent/Responsible Party Name

Full Name:
Cell #:
Work #:

Parent/Responsible Party Name

Full Name:
Cell #:
Work #:

Emergency Contact

Name:
Home Phone:
Work Phone:
Cell Phone:

Medical

Special Medical Conditions:
Learning Disabilities:
Allergic to:

Class:

Gymcarolina will call you within 24 hours to confirm availability in your requested class and to accept credit card payment over the phone.

Class:
Day:
Time:
Camp Week:

Payment Policy:

  • TUITION IS TO BE PAID IN FULL ON OR BEFORE THE FIRST CLASS OF EACH SESSION.
  • THERE IS A $25 SERVICE FEE FOR ALL RETURNED CHECKS.

Release:

I hereby acknowledge that I have been instructed by Gymcarolina that any activity involving height and motion may result in physical injury to my child, injuries which could result in paralysis. I have been assured that all precautions have been and will be reasonably undertaken by Gymcarolina to ensure my child's safety. In the event of an accident, I hereby waive and release Gymcarolina Gymnastics Academy from any and all claims of liability while my child is on the premises of the gymnastics facility, on a planned trip, or at a gymnastics meet. I understand that it is my/our responsibility to provide for medical insurance.

In lieu of a Doctor's certificate, I hereby state that my child is in sound physical and mental health, and has no specific medical or physical conditions except as stated above. In case of accident or sickness, I grant permission for a physician to administer necessary treatment to my child. I also authorize the adult staff members of Gymcarolina to act for me according to the best judgment in any emergency requiring medical attention.

I also hereby give Gymcarolina Gymnastics Academy permission to use a photograph of my child for advertising purposes.

I understand I am registering my child for the entire year. I agree to give a 30-day notice prior to termination. The sessions are my payment schedule and I do not need to re-register my child at the beginning of each session.


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