2021 REGISTRATION ENROLMENT FORM - 3YR OLD KINDERGYM PROGRAM

Are you a returning member from 2020? *

YES NO, I am a new Member If YES, Do you have a valid Kindergym Card

Child's Name *

First Name Last Name

Gender *

Male Female

Date of Birth *

Month Day Year

Select Day Option 1 *

	Monday	Tuesday	Wednesday	Thursday	Friday
10:00am to 10:45am

Select Day Option 2 (if we cannot accommodate your first option) *

	Monday	Tuesday	Wednesday	Thursday	Friday
10:00am to 10:45am

Parent/Guardian Name *

First Name Last Name

Email *

Mobile Phone Number *

Address *

Street Address

Street Address Line 2

Suburb

Potcode

Medical Information - Yes - Please provide details of any medical, sport injuries, physical or intellectual conditions that may have bearing on your child's ability, safety or behavior in class. (ie: epilepsy, asthma, growth related). If your child suffers from any allergies or is on any medication or currently in treatment for injuries that we should be made aware of. If not - Please type No *

DISCLAIMER - We, the Pivotal Gymnastics Management, and its Board of Management, committee members, officers and members of the body corporate (hereinafter referred to as “PGM”), advise that the learning of and participating in the sport of gymnastics, by its very nature, contains an element of risk. Whilst all due care and caution is undertaken to ensure the safety and wellbeing of gymnasts under the care of PGM, no liability is accepted for injury sustained whilst under that care. The personal information provided by you on this form will be used in accordance with our Privacy Policy. To obtain a copy of our Privacy Policy, enquire about any privacy issue, or make a request for access to information, please contact the Business Manager at PGM.

Emergency Contact Name *

Emergency Contact Number *

Relationship to child

Preferred Dr

Dr's Phone

Medicare Number

Name of Private Health Fund

APPLICATION FOR REGISTRATION - I/ We the undersigned applicant, having read the conditions outlined, in addition to the DISCLAIMER, and agreeing to abide by the Constitution, Board Resolutions and Club Rules in force at any time, hereby apply for registration to the Pivotal Gymnastics Management. Furthermore, I authorise my child’s coach to obtain any medical assistance that is deemed necessary formyself/ my child, in the case of an emergency, and agree to pay all medical expenses incurred through the emergency. The PGM may at its discretion commence proceedings or engage debt collectors to recover fees outstanding for a period in excess of sixty (60) days. The expense of debt recovery will be a cost to the member or former member and will be added to the amount of any outstanding fees. I agree to these terms

I agree to the above statement *

YES NO

Photo Release for Minors (if under 18yrs)

Northern Districts Gymnastic Club has my permission to use my or my child's photograph publicly to promote the gym. I understand that the images may be used in print publications, presentations, websites and social media.

Please select *

YES, I consent to the photo release of minors NO, I do not consent to the photo release of minors

How did you hear about us? *

Social Media Schools Returning Member Friends or Family

Signature *

Clear

2021 REGISTRATION ENROLMENT FORM 3 YEAR OLD KINDERGYM PROGRAM

Photo Release for Minors (if under 18yrs)