STUDENT NAME____________________________________  TODAYS DATE_______
DATE OF BIRTH__/__/__   AGE TODAY_______________ SEX_______
ADDRESS______________________________________CITY,_____________STATE ___ ZIP _____________
#1 PARENT NAME________________________HM PHONE___________________CELL ___________________
WKPHONE___________________________________Email:_________________________________
#2 PARENTNAME________________________HM PHONE____________________CELL _________________
Address if different from above________________________WKPHONE______________Email:________________
MY HEALTH/ACCIDENT POLICY IS WITH_______________WHOSE Phone # is_____________________________
POLICYHOLDER NAME________________________ POLICY NUMBER_________________________________
THIS POLICY DOES/DOES NOT COVER MY CHILD (NAME)___________________________________________
My Child _____________has had ___Years of gymnastics experience at _______________Studio/gym, and ended at
level__________.  My Child has ____ years of dance experience from ____________________studio.
How did you find out about us, PLEASE CIRCLE ONE BELOW:
Ad in paper    or    A friend     or    web search  or  USA Gymnastics  or Building Sign

Class or Session You Are Registering For:
__________________________________________________________

Siblings:
Name_____________________________________________age________ Birthday________
Name_____________________________________________age________ Birthday________

Extra Emergency Phone Numbers (in case we can not reach the above parents)
Name___________________________________Phone_______________
Name___________________________________Phone_______________

MEDICAL INFORMATION:
List ANY medical problems, allergies, chronic symptoms, or medications being taken.______________
SPECIAL DIETARY NEEDS_________________________.
RELEASE AND WAIVER OF LIABILITY/IMPLIED CONSENT FORM:
I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis and even death, as well as other damages
and losses associated with participation in gymnastics activities, cheer, and gymnastics/cheer/and Trampoline events.
Printed name of Student    ___________________________________
Printed name of Parent/Guardian__________________________________________
Signature of Parent/Guardian ______________________________Date:___/___/___

Please read the following carefully and sign below.  NOTE:  Parent signs if student is under 18 years.
Athlete Membership Agreement and information.  Fill in all blanks; submit forms for current season only, bearing original
signatures (photocopies or facsimiles not acceptable).
Agreement
In consideration of my membership in “Jumpin Gymnastics”, and my participation in “Jumpin Gymnastics” classes, events
and activities, I agree to be bound by each of the following:
1.  Eligibility:  I agree to comply with all the rules of “Jumpin Gymnastics” for which have been explained to me and a copy of these rules
given to me.

2.  Readiness to Participate:  I will only participate in those “Jumpin Gymnastics” classes, events, competitions and activities for which I
believe I am physically and psychologically prepared.  Prior to participation, I will have practiced my exercises and will perform only those
exercises, which I have accomplished to the degree of confidence necessary to assure I can perform them by myself, and without injury.

3.  Medical Attention:  I hereby give my consent to “Jumpin Gymnastics” and / or the Host Organization to provide, through a medical staff of
its choice, customary medical/athletic training attention, transportation, and emergency medical services as warranted in the course of my
participation.

4.  Waiver and Release:  I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis and even death, as
well as other damages and losses associated with participation.

5. Photo and Video Release: I hereby grant Jumpin Gymnastics permission to use mine or my child’s likeness in photographs and video  
in any and all publications and in any and all other media, whether now known or hereafter existing, controlled by Jumpin Gymnastics, in
perpetuity, and for other use by Jumpin Gymnastics. I will make no monetary or other claim against Jumpin Gymnastics for the use of the
photographs or video.

I further agree that “Jumpin Gymnastics” and the sponsor of any “Jumpin Gymnastics” event, along with the employees, agents, officers
and directors of these organizations shall not be liable for any losses or damages occurring as a result of my participation in the event,
except where such loss or damage is the result of the intentional or reckless conduct of one of the organizations or individuals identified
above.
Information
Primary Medical Insurance:  I am FULLY covered by a primary health/medical/accident insurance through:
____________________________________________________________________________________________
I am a citizen of the U.S.  ___Yes    ___No  Signature of Athlete (if over 18) :___________________
Printed Name of Athlete:___________________________

For any athlete who is not yet 18 years old:  As legal parent or guardian of this athlete, I hereby verify by my signature below that I fully
understand and accept each of the above conditions for permitting my child to participate in classes, events, competitions, and activities
conducted by “Jumpin Gymnastics”

Printed name of Parent/Guardian________________________________________________________________
Signature of Parent/Guardian_____________________________________________     Date:___/___/___

School Waiver and Release Form
I fully understand that “Jumpin Gymnastics” staff members are not physicians or medical practitioners of any kind.  With the above in mind, I
hereby release “Jumpin Gymnastics” staff to render temporary first aid to my child or children in the event of any injury or illness, and if
deemed necessary by the “Jumpin Gymnastics” staff, to call our doctor and to seek medical help, including transportation by a “Jumpin
Gymnastics” staff member or its representatives, whether paid or volunteer, to any health care facility or hospital, or the calling of an
ambulance for said child should the “Jumpin Gymnastics” staff deem this to be necessary.

Parent/GuardianSignature: __________________________________  Date:___/___/___

We, the staff of “Jumpin Gymnastics” recognize our obligation to make our students and their parents aware of the risks and hazards
associated with the sport of gymnastics, trampoline, tumbling, cheerleading and dance.  Students may suffer injuries, possibly minor,
serious or catastrophic in nature.  Gymnastics, tumbling, cheerleading, trampoline, and dance can be dangerous and can lead to injury.  
Parents should make their children aware of the possibility of injury and encourage their children to follow all the safety rules and the
coaches’ instructions. In signing this form, I understand that I waive the right to sue “JUMPIN GYMNASTIC LLC” (JG’S LLC) or any group or
individual associated with JG’S LLC, for both myself and my heirs, assigns, or personal representatives.

Parent/GuardianSignature: __________________________________  Date:___/___/___

“Jumpin Gymnastics”, its coaches and other staff members, will not accept responsibility for injuries sustained by any student during the
course of gymnastics, tumbling, cheerleading, trampoline, or dance instruction, or open work outs, or in the course of any exhibition,
competition or clinic in which he or she 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 or children participate
in the programs offered by “Jumpin Gymnastics”.  I, my executors or other representatives, waive and release all rights and claims for
damages that I or my child may have against “Jumpin Gymnastics” and/or its representatives, whether paid or volunteer. I also affirm that I
now have and will continue to provide proper hospitalization, health and accident insurance coverage that I consider adequate for both my
child’s protection and my own protection.  I also understand that it is the parent’s responsibility to warn the child about the dangers of
gymnastics and injury.  The parent should warn the child according to what the parent feels is appropriate.  “Jumpin Gymnastics” will only
warn the child through “Safety Messages” and our teaching style and progressions.

Parent/Guardian Signature: ____________________________________________      Date:___/___/___     
STUDENT REGISTRATION
copy and paste in an email to flip@jumpingymnastics.com (and pay registration now)
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