REGISTRATION FORM

 HALKER’S GOLD GYMNASTICS (GOLD MEDAL GYMNASTICS, INC.)

STUDENT NAME______________________________________________________SEX_____AGE_____D.O.B._____/_____/_____

 ADDRESS____________________________________________CITY_____________________STATE_______ZIP______________

 HOME PHONE__________________CELL PHONE___________________EMAIL________________________________________

 MOTHER’S NAME____________________PLACE OF EMPLOYMENT_____________OCCUPATION_____________WORK PHONE_____________________

 FATHER’S NAME_____________________PLACE OF EMPLOYMENT_____________OCCUPATION_____________WORK PHONE_____________________

 ARE THERE ANY MEDICAL CONDITIONS TO WHICH WE SHOULD BE ALERTED_____________________________________________________________

CLASS CHOICE (PLEASE CIRCLE CLASS LOCATION BELOW)

OTTAWA                             LAFAYETTE                        BLUFFTON

        CLASS CHOISE:                        DAY_____________TIME______________

ENCLOSED IS THE $25.00 REGISTRATION                                              $______________

 ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY & PROMISE TO PAY

As Legal guardian of , and or  participant ____________________________, I hereby consent to the aforementioned person participating in the Halker’s Gold Gymnastics (Gold Medal Gymnastics, Inc.) programs.  I understand the nature of this activity and I feel I or my minor is in good health and proper physical condition to participate in such Activity.  I recognize that potentially severe injuries, including sprains, strains, broken bones, permanent paralysis or death can occur in any activity involving height or motion, including gymnastics, cheerleading, and any other activities at Halker’s Gold Gyimnastics (Gold Medal Gymnastics, Inc..) provides.  I UNDERSTAND AND ACCEPT THAT RISK.  I also realize that my child will be performing and training on all gymnastics events, plus various other training devices including the trampoline.  I understand the nature of this activity and believe the minor to be healthy and physically able to participate in such activity.

I further understand that while the payment of tuition and registration fees constitutes a part of the consideration due to Halker’s Gold Gymnastics (Gold Medal Gymnastics, Inc.) an additional and important part of the consideration due to Halker’s Gold Gymnastics (Gold Medal Gymnastics, Inc.) is this sign release form.  Therefore, in consideration for and allowing my child to use the Halker’s Gold Gymnastics (Gold Medal Gymnastics, Inc.) equipment and facilities and or rented facility.  I hereby forever release the Halker’s Gold Gymnastics (Gold Medal Gymnastics, Inc., its 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 Halker’s Gold Gymnastics (Gold Medal Gymnastics, Inc.), it’s owners, officers, employees, teachers, or coaches.  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 a result of any such claim.

As a parent or legal guardian of the aforementioned person, I hereby agree to individually provide for the possible future medical expenses which may be incurred by my child as a result of any injury sustained while training or performing for Halker’s Gold Gymnastics (Gold Medal Gymnastics, Inc.)

I also understand the payment policies, yearly, monthly, and hourly fees, and agree to make prompt payment.  If billing is required I will be charged a $5.00 billing fee per month as well as any expenses Halker’s Gold Gymnastics (Gold Medal Gymnastics, Inc.) incurs to collect any unpaid fees.  I also realize that this registration fee is non-refundable.

This acknowledgement of risk and liability, and promise to pay, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.

I also give my permission to trained medical professionals to administer emergency medical treatment to my child, should sickness or accident occur in my absence.

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PRINTED NAME OF PARTICIPANT

 _______________________________________________________                                  __________________

     PARTICIPANT SIGNATURE                                                                                            DATE

 _______________________________________________________

      PRINTED NAME OF LEGAL GUARDIAN

 _______________________________________________________                                  __________________

      PARENT OR LEGAL GUARDIAN SIGNATURE                                                            DATE