REGISTRATION FORM

Sapphire

Gymnastics Academy

Registration Form

Student’s Name: M / F DOB:

Parent(s) Name(s):

CONTACT INFORMATION

Street Address: City: Zip:

Home Phone:

Mom’s Cell: Dad’s Cell:

Mom Work Phone: Dad Work Phone:

Mom Work Name: Dad Work Name:

E-mail (mandatory):

Alternative E-mail

EMERGENCY CONTACT information

Name:

Relationship to child: Home Phone: Cell Phone: Alternative Cell:

Please list any medical conditions of which we should be aware:

How did you hear about Sapphire Gymnastics Academy?

Event X ____________________ Referral X ______________________

Web X ____________________ Phonebook X ______________________

Returning Member X ____________________ Other X ____________________

CAUTION – ACKNOWLEDGEMENT OF RISK AND WAIVER OF LIABILITY – READ BEFORE SIGNING!

Name of child(ren):

Name of parent(s):

I (we) recognize that despite all reasonable precautions implemented for safety, potentially severe injuries including permanent paralysis or death can occur in any activity involving height or motion, including, but not limited to gymnastics, tumbling, trampoline and cheerleading. I (we) knowingly and willingly assume all such risks and therefore I consent to the aforementioned person and/or myself participating in Sapphire Gymnastics Academy, L.L.C’s programs. Consequently I (we) hereby for myself, heirs, executors and administrators, do waive and release any and all rights and claims for damages against members, operators, coaches and other members of Sapphire Gymnastics Academy, L.L.C. from personal injury or accident of any sort or nature suffered by myself or my child by reason of participation or membership in classes, lessons or any programs or activities of Sapphire Gymnastics Academy. In addition, I hereby give permission to trained medical professionals to administer emergency medical treatment to my child(ren) should sickness or accident occur in my absence.

I (we), as the parents or guardians of the above named student(s) fully authorize and grant Sapphire Gymnastics Academy and its authorized representatives the right to print, photograph, record and edit as desired the biographical information, name, image, likeness and/or voice of the above named pupil(s) on audio, video, film, slide, or any other electronic and printed formats. I understand that use of such recordings or imaging, will be without any compensation to the student(s)’ parent or guardian. I hereby release and hold harmless SGA and its authorized representatives from any and all actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the student(s) and/or parent or guardian which relate to or arise out of any of these recordings/imaging.

Parent or Guardian X Date: