2022 REGISTRATION ENROLMENT FORM 9 -13 YEAR OLDS FREESTYLE GYMNASTICS PROGRAM
(Born 2013 or earlier) Please complete one form per child
Are you a returning member from 2021?
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YES, I am a returning member
NO, I am a new Member
Child's Name
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First Name
Last Name
Gender
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Male
Female
Date of Birth
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Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
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1936
1935
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Select Day Option 1
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Monday
Tuesday
Wednesday
Thursday
Saturday
6:15pm to 745pm
10:30am to 12noon
Saturday Only
Select Day Option 2 (if we cannot accommodate your first option)
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Monday
Tuesday
Wednesday
Thursday
Saturday
6:15pm to 7:45pm
10:30am to 12noon
Saturday Only
Friend Request
We will do our very best to meet your request.
Parent/Guardian Name
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First Name
Last Name
Email
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Mobile Phone Number
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Address
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Street Address
Street Address Line 2
City
Suburb
Postcode
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.
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I have read and understood the above disclaimer
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
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Emergency Contact Name
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Emergency Contact Number
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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 for myself/ 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 the above statement
YES, I agree to the above statement
NO, I disagree to the above statement
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.
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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?
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Social Media
Schools
Returning Member
Friends or Family
Signature
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Print Form
Submit
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