CCGI
9514 W. PERSHING AVE, VISALIA
(559) 651-2244
1ST CHILDS NAME: ___________________________________ Birthday: ______________________
CLASS DAY & TIME: ____________ SESSION:_________
2nd CHILDS NAME: ___________________________________ Birthday: ______________________
CLASS DAY & TIME: ____________ SESSION:_________
3rd CHILDS NAME: _______Birthday: ______________________
CLASS DAY & TIME: ____________ SESSION:_________
PHONE: CELL/PAGER: PARENTS SSN#:
ADDRESS: CITY: ZIP:
FATHER: ________________Occupation: WK #:
MOTHER: Occupation: WK #:
DOCTOR & INSURANCE:
EMERGENCY CONTACT (NAME & NUMBER): ______
ANY MEDICAL CONDITIONS WE NEED TO BE AWARE OF: ______
REFERRED BY: _________________________
Email Address: ______________________________________
IMPORTANT MEMBER INFORMATION
REGISTRATION- THERE SHALL BE A REGISTRATION FEE OF $45.00. THIS FEE IS PAID ANNUALLY, AND MEMBERS WILL BE BILLED EACH SUBSEQUENT SEPTEMBER.
FEES ARE DUE AND PAYABLE BY THE 1ST WEEK OF EACH SESSION. IF FEES ARE NOT RECEIVED BY THE END OF THE 1ST WEEK OF EACH SESSION, A LATE CHARGE OF $10 WILL BE ASSESSED FOR EACH CHILD. IF PAYMENT HAS NOT BEEN RECEIVED BY END OF THE 2ND WEEK OF EACH SESSION, THE GYMNAST WILL NOT BE ALLOWED TO CONTINUE WORKING OUT UNTIL ARRANGEMENTS HAVE BEEN MADE. FOR STUDENTS REGISTERING AFTER THE 1ST OF THE SESSION, FEES WILL BE PRO-RATED ACCORDINGLY. UNPAID ACCOUNTS AFTER 90 DAYS WILL BE SENT TO COLLECTIONS.
I UNDERSTAND THAT ALL PAYMENTS ARE NON-REFUNDABLE. INITIAL______________
I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF THE SPOT MY CHILD HOLDS IN CLASS UNTIL CCGI IS NOTIFIED IN WRITING THAT HE OR SHE WILL NOT BE RETURNING TO CLASS.
INITIAL ______________
I HAVE READ CCGI’S FEE INFORMATION, RULES AND REGULATIONS, AND AGREE TO ABIDE BY THEM.
PARENT OR LEGAL GUARDIAN____________________________________________________DATE__________
I HEREBY AUTHORIZE THE STAFF OF CCGI TO SEEK MEDICAL TREATMENT FOR MY CHILD, AS LISTED ON THE REVERSE, IN CASE OF EMERGENCY WHEN I CANNOT BE REACHED.
PARENT OR LEGAL GUARDIAN____________________________________________________DATE__________
ACKNOWLEDGEMENT OF RISK AND WAIVER OF LIABILITY
As the parent or legal guardian of ,
I hereby consent to the above named person participating in the programs offered by Central California Gymnastics Institute, Inc. (CCGI). I recognize that the potentially severe injuries, including sprains, strains, broken bones, permanent paralysis, or death can occur in any activity involving height or motion, including gymnastics, dance, and/or karate. I UNDERSTAND AND ACCEPT THAT RISK. I also recognize that my child will be performing and training on all gymnastics, cheerleading, and /or dance events plus various other training devises including the trampoline.
I further understand that while the payments of tuition and registration fees constitutes a part of the consideration due to CCGI, an additional and important part of the consideration due to CCGI is this signed release form. Therefore, in consideration for allowing my child to use the CCGI equipment and facilities I hereby forever release CCGI, its owners, officers, employees, teachers, and coaches from all liability for any and all damages and injuries suffered by my child while under the instruction, supervision, or control of CCGI its owners, officers, employees, teachers, or coaches.
As the parent or legal guardian of the aforementioned person, I hereby agree to individually protect for the possible future medical expenses which may be incurred by my child as a result of any injury sustained while training at, for, or under the direction of CCGI.
This acknowledgement of risk and waiver of liability, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.
PRINT PARENT’S NAME: _____Date: _____________
SIGNATURE:
