Flipnastics, LLC Platinum Gymnastics Academy Class Registration / Waiver Form

For Office Use Only Class Assignment: _________________________________ $______Reg. $______Dep. $______Tuit. Total Due: $______Reg. $______Dep. $______Tuit.

Participant Information: Last Name: ___________________________ First Name :________________________ DOB:_______________ Gender: M / F Last Name: ___________________________ First Name :________________________ DOB:_______________ Gender: M / F Home Phone: _________________________ Address:______________________________________ City:__________________ State:______ Zip:______________ List Medical Conditions/Broken Bones/Allergies: ____________________________________________________________________ Insurance Company Name: __________________________________ Policy Number: _______________________________ Emergency Contact Name: __________________________________ Emergency Contact Phone: ______________________ Family Doctor Name: _______________________________________ Family Doctor Phone: __________________________ Parent/Guardian Information: Mothers Name: _________________________________ Fathers Name: _______________________________ Occupation: _____________________________________ Occupation: __________________________________ Cell Phone: ______________________________________ Cell Phone: __________________________________ Email: __________________________________________ Email: ______________________________________
In consideration of Flipnastics, LLC DBA: Platinum Gymnastics Academy (PGA) allowing the gymnasts/participants to participate in sports activity, class, competition, team, and non-gymnastics activities such as dance, open gym, inflatables, and playground activities (hereinafter referred to as the Activity), I, as legal guardian and/or participant agree to be bound as follows (the term I in this release refers to both the participants and his/her leg al guardian). Acknowledgment and Assumption of Risks. I understand that the Activity involves risks of serious bodily injury, including permanent disability, paralysis, and death, which may be caused by the participants actions or inactions, those of others participating in the Activity, the conditions in which the Activity takes place, the negligence of the Released Parties named below, or other causes. I fully accept and assume all such risks and all responsibility for losses, cost, and damages that may result from the Activity. I hereby give my approval of and consent for participation in the Activity. I assume all risks and hazards incidental to the Activity and to transportation to and from the Activity. I understand the nature of the Activity, and I represent that the gymnasts/participants is qualified, in good health, and in proper physical condition to participant in the Activity. Release. I hereby release, acquit, covenant not to sue, and forever discharge Flipnastics, LLC DBA: Platinum Gymnastics Academy, its owners, officers, administrators, employees, coaches and supervisors, and the owners or lessors of any facilities within which the Activity is conducted, and all other persons providing facilities or assisting in the conduct of the Activity and in the transportation of participants to and from the Activity (collectively the Released Parties) of and from any and all actions, causes of action, claims, demands, liability, losses or damages of whatever name or nature, including but not limited to those arising from or in any way related to the negligence of any of the Released Parties, that arise out of or are connected in any way to the gymnasts/participants participation in the Activity and the transportation of the above named gymnasts/participants to and from the Activity (collectively the Released Claims). Indemnification. I will defend, indemnify and hold harmless the Released Parties from (that is, to reimburse and be responsible for) and loss or damage, including but not limited to costs and reasonable attorneys fees (including the cost of any claim I might make or that might be made o n my behalf or the gymnasts/ participants behalf that is released in this document), arising out of or connected in any way with any of the Released Claims. Medical Attention: I fully understand that Flipnastics, LLC DBA: Platinum Gymnastics Academy (PGA) staff members are not physicians or medical practitioners of any kind. With the above in mind, I hereby release PGA staff to render first aid to my child(ren) in the event of any injury or illness, and if deemed necessary by the PGA staff, to provide through a medical staff of its choice, customary medical/athletic training attention, transportation by a PGA staff member or its representatives, whether paid or volunteer, or the calling of an ambulance. I also acknowledge that medical insurance is not provided by PGA. Platinum Policies: Tuition/Registration/Deposit - Due by the 5th of each month. After the 5th of the month, a $15.00 charge will be added to the account. After the 10th of the month, the athlete will be dropped from class. Tuition is based on a calendar year (4 or 5 weeks per month) and will not be adjusted for holidays or scheduled gym closings. There will be a $25.00 charge for returned checks. One months tuition is required for deposit. Deposits are non-refundable and used towards the athletes last month of classes upon a PGA written 60-Day Notice of Leaving (available at the front desk). Annual registration of $35.00 is due and payable in the month of August each year. Cancellations due to weather or circumstances beyond PGA control do not constitute a make-up class. PGA allows a set number of athletes in each class; therefore, in order to remain within guidelines, make-up classes due to athlete absence is not allowed. Photo Release On occasion, PGA or other parents may be taking photos of classes. PGA may use photos for print publications, website, email, press release, advertising, or any use of choice. PGA is not responsible for photos taken by other parents. By signing below, you also release PGA to use the participants name in such items listed here within. I have read and understand this PGA class registration/waiver form. I am executing this document voluntarily and with full knowledge of its significance.

_______________________________________________________________ _________________________ Signature of Parent/Guardian or Participant if 18 yrs or older Date