Class Registration and Payment - Country Gymnastics

How many children are you registering today?
- 1
- 2
- 3
Class Participant Information
Child's Name*
First Last
Child's Birthdate*
MM slash DD slash YYYY
MEDICAL CONDITIONS:*
List any medical concerns about which Country Gymnastics staff should be informed. All staff is HIPAA trained and medical concerns will be kept private. If none, please list "None."
Class Selection*

Child #2 Name*
First Last
Child #2 Birthdate*
MM slash DD slash YYYY
Child #2 MEDICAL CONDITIONS:*
List any medical concerns about which Country Gymnastics staff should be informed. All staff is HIPAA trained and medical concerns will be kept private. If none, please list "None."
Child #2 Class Selection*

Child #3 Name*
First Last
Child #3 Birthdate*
MM slash DD slash YYYY
Child #3 MEDICAL CONDITIONS:*
List any medical concerns about which Country Gymnastics staff should be informed. All staff is HIPAA trained and medical concerns will be kept private. If none, please list "None."
Child #3 Class Selection*

Parent/Guardian Contact Information
Parent/Guardian Name*
First Last
Parent/Guardian Phone*
Additional Parent/Guardian Name
First Last
Additional Parent/Guardian Phone
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email Address:*
Secondary Email Address:

Emergency Contact Information
Emergency Contact Name:*
First Last
Emergency Contact Phone:*

Insurance Information
Do you have medical insurance?*
- Yes
- No
Insurance Provider:*
Name of Insured*
First Last

Total Monthly Payment
10% Family Discount
Price: $0.00
15% Family Discount
Price: $0.00
Total
$0.00
After you click "Submit" at the end of this registration form, you'll be directed to PayPal to set up your monthly payment.
Comments/Questions

Legal Waiver - Signature Required
Waiver of Legal Claims and Indemnification/Allocation of Responsibility for Legal Claims
Country Gymnastics Center will take all precautions to prevent injury and insure every participant’s safety. Participants will be involved in physical activities that inherently involve the risk of injury. These risks include but are not limited to the following: Sprains, bruises, torn muscles, torn ligaments broken bones, dislocated joints, partial or total paralysis, or in some cases, death. I now acknowledge full understanding of theses inherent risks, and with full knowledge and understanding assume all such risks by permitting my child to participate in these activities. I confirm that the student being registered is in good physical condition and has no physical or medical conditions which will limit, interfere with or be aggravated by the student’s participation in the scheduled activities. I, the undersigned parent and/or legal guardian, on behalf of myself, my child and any person acquiring a right of action of behalf of my child, hereby WAIVE ANY RIGHT TO SEEK DAMAGES from or against Country Gymnastics Center, its agents, employees and independent contractors, for ANY personal injuries, accidents, financial damages or other consequential damages of any kind whatsoever, arising from or related to my child’s activities at Country Gymnastics Center. I further knowingly release Country Gymnastics Center, and its agents, employees and independent contractors, form any liability or damage incurred by or associated with my child’s activities at Country Gymnastics Center or functions hosted or attended by Country Gymnastics Center. In addition to my release, discharge and covenant to not sue, I agree to indemnify, save and hold harmless each of the releasees from all liability claims, demands, losses or damages on the minor’s account, including negligent rescue operations. If, despite this release, I, the minor, or anyone on the minor’s behalf makes a claim against any of the releases named above, I will indemnify, save and hold harmless each of the releasees from any litigation expenses, attorney’s fees, loss liability, damage or cost incurred as the result of any such claim. I will be personally responsible for any and all of these claims and all expenses incurred by these claims.
By typing your name below, you accept the terms of the waiver above:*

Class Registration and Payment Form

Step 1 of 8

Class Participant Information

Parent/Guardian Contact Information

Emergency Contact Information

Insurance Information

Total Monthly Payment

After you click "Submit" at the end of this registration form, you'll be directed to PayPal to set up your monthly payment.

Legal Waiver - Signature Required