REGISTRATION FORM & WAIVER

 

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

 

Student’s Age:  ___________             Sex:  _______   Birthday:  ______________   

 

Class Day & Time Registering For (circle choice):     

 

KinderGym(3yrs) / Tiny Tot(2yrs):      Tues 5:00          Tues 6:00          Thurs 5:30

 

Girls Recreational Gym (4yrs&up):     Tues 4:00          Tues 5:00          Thurs 4:30          Thurs 5:30

 

Boys Recreational Gym (4yrs&up):      Tues 5:00          Thurs 5:30                       

 

Tumbling (7yrs&up):      Tues 6:00          Thurs 6:30         

 

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

 

Father’s Home Address: _____________________________City:  ________________  Zip Code: ________

 

Father’s Cell or Primary Phone #:  ___________________  Email:  _________________________________           

 

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

 

Mother’s Home Address: _____________________________City:  ________________  Zip Code: ________

 

Mother’s Cell or Primary Phone #:  ___________________  Email:  _________________________________           

 

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Emergency Contact Name:  _________________________ Emergency #s:  __________________________

 

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PAYMENT INFORMATION

 

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

(if no credit card on file, payment due on 1st class day of month BEFORE attending class, $20 late fee after 15th, credit cards do incur a 5% service charge)

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MEDICAL INFORMATION

 

List any physical or psychological handicaps (specify bodily part, weaknesses, anxiety, fear, etc.): 

_____________________________________________________________________________________

_____________________________________________________________________________________

 

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

_____________________________________________________________________________________

_____________________________________________________________________________________

 

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 these sports.  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 sports offered by New Heights Gym.  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 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 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 am aware that New Heights Gym has taken reasonable measures to prevent the spread of infectious diseases and that I as a parent or legal guardian will also take reasonable measures to ensure that we and our child are not contagious before entering New Heights Gym. I agree to not send my child to class if he/she shows any signs or symptoms of being sick.

 

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:  __________________

We have finally moved into the modern world of payment with the Venmo app! If you choose to use the Venmo app to pay for registration, tuition, camp, or snack account please make sure your child's name and what you are paying for is listed in the Memo space. 

Contact

1204 Import Drive

New Iberia, LA 70560

​​

Tel: 337-365-3806

Email: leleux@mindspring.com

Website: www.newheightsgym.org

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