Gymnast/Child Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Medicare Number
Gymnast/Child Position on Medicare Card
Gymnast/Child Mobile Phone (if any)
Parent 1 Name
First Name
Last Name
Parent 2 Name
First Name
Last Name
Parent 1 Mobile
*
Parent 2 Mobile
Email
*
Parent 1 Occupation
Parent 2 Occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name (not in your household)
First Name
Last Name
Emergency Contact Phone Number
*
Emergency Contact Person's Relationship to Gymnast
*
If you are new to NCG how did you hear about us?
Please Select
Through a friend
Social Media
Through my child's school program
Lismore Tourism Website
Ballina Tourism Website
Driving By
TV
Newspaper
Other
Medical Details
*
No Conditions to Report
Asthma
Heart Condition
Stroke
Previous Broken Bone
Previous Concussion
Previous Neck Injury
Diabetes
Epilepsy (please identify trigger in further information)
Previous Major Surgery
Dizziness
Hemophilia/Bleeding
Anaemia
Recent Major Illness
Allergies (please supply your Allergy Plan from your Dr)
Risk Management Plan
Immunisation is Up To Date
COVID-19 Vaccine
Hearing Loss/Difficulty
Vision Loss/Difficulty
Learning Difficulty (please supply further information)
Speech Difficulty
Mobilty/Disability we should be aware of (please supply further information)
Medications or Precautions we should be aware of (please supply further information)
Other (please supply further information)
Further Information for Anything You Have Checked in Medical Details
Preferred Treating Doctor
Please Select
Please contact the named Doctor
Not Applicable
Any Available
Preferred Treating Doctor
First Name
Last Name
Doctor Phone Number
Private Health Insurance
*
Please Select
Yes
No
Ambulance Cover
*
Please Select
Yes
No
Permission to Transport To Hospital
*
Please Select
Yes
No
OUR TERMS
The customer (Gymnast & Parent/Carer) acknowledges that the proprietor (North Coast Gymnastics) relies on the information provided by the customer, and the customer states that all such information is accurate and complete. The customer must disclose any pre-existing medical and/or other condition that may affect the risk that either the customer or any other person may suffer including injury, loss, and/or damage.
The customer agrees with the proprietor that the customer will obey and comply with all the rules and directions made or given by the proprietor in connection with the activity of NCG. If the customer fails to comply with the proprietor’s rules and/or directions, the customer will be involved in the Code of Behavior process and may not be permitted to continue gymnastics activities.
The customer accepts all risks associated with the activity, including the possibility of injury, death, loss and/or damage. All accidents, injuries, loss and/or damage must be reported by the customer to the proprietor before the customer leaves the premises.
If the customer suffers an injury or illness, the customer agrees that the proprietor may provide evacuation, first aid, and medical treatment at the customer’s expense and that the customer’s acceptance of these terms and conditions constitutes the customers consent to such evacuation, first aid and/or medical treatment.
Please note, these terms and conditions do not remove the NCG’s responsibility to provide a safe environment. NCG is committed to maintain their Duty of Care.
I give permission for my child to be photographed/videoed while participating in club activities. I consent for the photos/video to be used without payment for the sole use of marketing/promotional purposes by/for North Coast Gymnastics (NCG).
*
Please Select
Yes
No
I give permission for my child to receive medical/ambulance assistance in case of emergency and agree to pay such costs incurred.
*
Please Select
Yes
No
I understand that I may access my child’s personal information held by NCG upon written request.
*
Please Select
Yes
No
I understand a formal member policy is effect and is available upon written request.
*
Please Select
Yes
No
The information provided on this form is complete and correct to the best of my knowledge and I undertake to advise NCG promptly of any changes that may occur.
*
Please Select
Yes
No
I have read and understand this registration application and NCG’s rules and agree to the terms and conditions stated therein.
*
Please Select
Yes
No
I agree to the above terms and conditions and agree to pay the prescribed fee for tuition and registration.
*
Please Select
Yes
No
Signature Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Signature
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