Contact

1204 Import Drive

New Iberia, LA 70560

​​

Tel: 337-365-3806

Email: leleux@mindspring.com

Website: www.newheightsgym.org

  • Black Facebook Icon
  • Black Twitter Icon
  • Black Instagram Icon
  • Black YouTube Icon
  • Black Google+ Icon

© 2023 by Personal Life Coach. Proudly created with Wix.com

REGISTRATION FORM & WAIVER

 

STUDENT INFORMATION

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

 

Class Registering For:  ________________________           Class Day & Time:  _____________________

 

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

 

***************************************************************************************************

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

 

Father’s Home Address & Zip Code: _______________________________Home Phone:  _____________  

 

Father’s Cell:  _____________  Father’s Work #:  ______________  Email:  _________________________      

 

***************************************************************************************

Mother’s Name:  _______________________________________________Primary Guardian? Yes  or  No

 

Mother’s Home Address & Zip Code: ______________________________Home Phone:  ______________  

 

Mother’s Cell:  ____________  Mother’s Work #:  _____________  Email:  __________________________

 

***************************************************************************************

Emergency Contact Name:  _________________________ Emergency #s:  _________________________

 

***************************************************************************************

PAYMENT INFORMATION

 

Credit Card Type:_______  CC #:______________________  Exp:_______  CVV:______  Zip:_________

(without credit card on file, payment due before 10th of month otherwise $10 late fee)

****************************************************************************************************

MEDICAL INFORMATION

 

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

_________________________________________________________________________________________

_________________________________________________________________________________________

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

_____________________________________________________________________________________

_____________________________________________________________________________________

 

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

_____________________________________________________________________________________

_____________________________________________________________________________________

 

List any allergies:  ______________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

Insurance Company:  _______________________________           Policy #:  _______________________

(student must have own insurance coverage, NHG does not provide insurance)

 

 WAIVER OF LIABILITY

 

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, DANCING 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, dancing 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 further understand that there are risks of concussions in any sports activity and that concussions may occur and not be recognized.  If suspected of having a concussion, I agree to have a doctor’s release before returning to class. 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.

 

I understand that there may be times throughout the year the media or New Heights Gym staff may take photographs or audio/videotapes of students in a group setting or in a manner that individually identifies a specific student. New Heights Gym may display these pictures or video footage in a variety of ways that reasonably portray programs of New Heights Gym in local publications and on the gym web site.  I release the owners of New Heights Gym from any compensation or damages in its use of photographs or audio/video tapes for dissemination via the website, print, or cable access channel.  Please circle your choice for each:

 

  • I DO / DO NOT give permission for my child to be individually photographed or audio/videotaped by the media.

  • I DO / DO NOT give permission for my child to be individually photographed or audio/video taped by New Heights Gym personnel for broadcast on news media.

  • I DO / DO NOT give permission for my child’s photograph to appear on the Gym web site or in publications.

 

Parent’s Printed Name:  ________________________  Parent’s Signature:  ___________________________

 

Student’s Name:  ______________________________________                           Date:  ________________