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Dancing Registration Forms
Stephanie Robinson - Director/Instructor
STUDENT REGISTRATION FORM
Student’s Name:______________________________________________________________________
Age:________________________
Date of Birth:______________________________________
School Attending:________________________________________________Grade:_______________
The 2010 - 2011 Dance Session will be my ____________________________________year of dance
(This is for awards at the end of the year.
Accuracy is your responsibility)
Mother’s Name:____________________________Father’s Name:_____________________________
Student’s Address:____________________________________________________________________
City:_________________________________________ State:________________ Zip:_____________
Home Phone:________________________________________________________________________
Mother’s Cell:_____________________________Father’s Cell:_______________________________
Emergency Contact__________________________________ Emergency #_____________________
E-mail Address:_______________________________________________________________________
Referred by:__________________________________________________________________________
NEW HEIGHTS GYMWAIVER OF RESPONSIBILITY AND MEDICAL RELEASE
In consideration of being accepted as a member of New Heights Gym, I agree to abide by the rules of this organization and all applicable by-laws of USA Gymnastics and/or USA Track & Field and/or AAU. GYMNASTICS, TUMBLING, CHEERLEADING, KARATE AND POLE VAULTING ARE POTENTIALLY DANGEROUS SPORTS AND CAN LEAD TO INJURY. I understand that New Heights Gym, LLC has an obligation to make the students and their parents aware of the risks and hazards associated with the sports of gymnastics, tumbling, cheerleading, karate and pole vaulting. I understand that as a parent, I am responsible in making my child aware of the possibility of injury and to encourage my child to follow all safety rules and the coaches’ instructions. Students should never engage in activity without supervision. Students should wear appropriate attire for all activities. Clothing, whether too baggy or too tight, can impede movements and reduce safety. Students should not wear jewelry and should have hair under control so that vision is not impaired. Students should report to the coach anything that will compromise their ability to perform, such as being ill, angry, fatigued, frustrated, or on medication. Students should be able to communicate their comfort level with skills as they are presented and mastered. Students should not pursue skills or activities that exceed their current abilities. I assume full responsibility for my own safety and the safety of my child, understanding and accepting the risks involved with the sport and training of gymnastics, tumbling, cheerleading, karate and pole vaulting. I agree not to bring any claim or suit against New Heights Gym, LLC, the owners, instructors, staff, guests, students, or any other parties on my behalf or on behalf of my child for any injury or harm sustained by any event short of criminal act, and then only the criminal shall be the subject of that claim or suit. I further agree that I will not cause to be brought, nor encourage a claim or suit. I also agree not to cooperate in the bringing of such a suit or claim, except insofar as I may be legally required to do so. Finally, I shall indemnify New Heights Gym, LLC, the owners, instructors, staff, guests, students, and any and all additional defendants covered by this agreement for all judgments, costs, attorney fees, and other expenses incurred as a result of a breach of this agreement. New Heights Gym, LLC, its owners, coaches, and other staff members will not accept responsibility for injuries sustained by a student during instruction, or open workouts, or in the course of any exhibition, competition, or clinic in which the child may participate or while traveling to or from the event. With the above in mind, and being fully aware of the risks and possibility of injury involved, I consent to have my child participate in the programs offered by New Heights Gym, LLC. I waive and release all rights and claims for damages that my child or I may have against New Heights Gym, LLC or its representatives whether paid or volunteer.
I understand that New Heights Gym, LLC staff members are not physicians or medical practitioners of any kind. I, the undersigned, give the instructors, staff and responsible adults the power to authorize medical or other treatment of the student named below. I understand that the instructors, senior students, or others may have some skills in first aid, CPR, and, at their discretion, I authorize them to use those skills and techniques to assist in any circumstances in which they judge their skills would be necessary or helpful. I hereby release New Heights Gym, LLC staff to render first aid to my child in the event of injury or illness, and if deemed necessary by New Heights Gym, LLC staff, the calling of an ambulance for the said child.
Parent’s Signature: ________________________________ Date: __________________
Student’s Name: __________________________________
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