NEW HEIGHTS GYM

DAY CAMP REGISTRATION

Student’s First Name:   ______________________    Student’s Last Name:   _________________________

Age:   ___________     Sex:   _________    Birthday:   ______________     Grade:   _____________________

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Father’s Name:   _________________________________     Primary Guardian?       Yes      or      No

Father’s Home Address: __________________________________________________________________

Father’s Home Phone:   ______________    Father’s Cell:   _____________   Father’s Work #:   ___________

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Mother’s Name:   _________________________________     Primary Guardian?       Yes      or      No

Mother’s Home Address: __________________________________________________________________

Mother’s Home Phone:   ______________    Mother’s Cell:   ____________   Mother’s Work #:   ___________

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Emergency Contacts:   ____________________________     Emergency #s:   __________________________

List Only Persons Allowed to Pick Up Child:   __________________________________________________

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MEDICAL INFORMATION

List any physical handicaps (specify bodily part, weaknesses, etc.):   _______________________________

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List any chronic ailments (asthma, heart problems, diabetes, epilepsy, hemophilia, etc.):   ______________

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List any psychological handicaps (anxiety, fear, hyperactivity, hypersensitivity, etc.):   ________________

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List any allergies:   ______________________________________________________________________

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List any other medical problems:   __________________________________________________________

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Insurance Company:   _______________________________            Policy #:   _______________________

CAMP WAIVER 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 USA Track & Field.   GYMNASTICS, TUMBLING, CHEERLEADING, and POLEVAULTING 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, and cheerleading.   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.   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, and cheerleading.   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.

As a parent I understand that some of the activities at New Heights Gym camp are potentially dangerous and do understand the requirement for safety, discipline, and the full attention of the students.  I understand that the child’s safety and best interest are the number one concern of New Heights Gym.  

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:   __________________________________