New Tumbler Registration Form

New Tumbler Registration Form
Childs Name*

First NameLast Name
Childs Birth Date*

MonthDayYear
Mothers Name*

First NameLast Name
Mothers Birth Date*

MonthDayYear
Fathers Name*

First NameLast Name
Fathers Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
How did you hear about us?*
Please Specify*
Signature*

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Payment: Automatic bank withdrawl

(Credit Card)- $55 Member/ $60 Non-Member
*I understand that if my childs tuition is not paid by the 1st of each month, class will be haulted until account is paid in full, if other dates of payment are needed, please notify!*

*If you are canceling tumbling class, you must cancel by the 25th of each month to stop the payment by the 1st of the following month!*
Before your athlete is able to join our classes, you must bring a form of payment for us to put on file with your account. Thank you!
Signature*

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INFORMED CONSENT AND RELEASE OF LIABILITY

PARENTAL CONSENT ON BEHALF OF MINORS

I am the parent/guardian of a minor (or minors if there are multiple children). On behalf of my child (children), I hereby accept and agree to the following:

In consideration of being permitted to use the facilities, equipment, programs and services of the EQT Rec Center (hereafter referred to as the “EQT”), I hereby release, acquit and discharge EQT, the Greene County Memorial Hospital Foundation (“Owner”), Healthplex Associates, Inc. (“HPA”), their successors and assigns, and their officers, directors, agents, and employees (all of whom shall collectively be referred to hereafter as the “Center”) of and from all claims and liability of any kind which arise from my own or my child’s negligence or misuse of the EQT and I agree that I will not sue or commence any action of any kind against the Center, their successors and assigns and their officers, directors, agents, or employees, for damages which arise from my (or my child/children’s) own negligence or misuse.

With respect to my child/children’s participation in any physical activity, sports or exercise program and/or use of any of EQT, I understand that there may be health risks associated with these activities. I assume full responsibility for any and all injuries, illnesses, or damages from the risks of their participation in the activities in, on, around, about or outside of EQT which may hereafter occur to my child/children.

I certify that my child/children are capable of performing physical exercise and I am responsible for obtaining and reviewing any physician-prescribed personal wellness program with my child/children’s physician prior to my commencing physical activities and will periodically review their status and program with their physician. If they experience dizziness, fainting, nausea, muscle cramping or any other symptoms while participating in the physical activities, I will discontinue their activity, notify the Center staff or the HPA staff, and consult their physician.

In consideration of my child/children being permitted to participate in the EQT activities in, on, around, about or outside of the EQT and use any equipment therein, I hereby waive any and all claims I may have, on behalf of myself, my heirs, executors, administrators and assigns, against the Center from all liability for injury, illness, death, or loss suffered by me while participating in any activity at EQT which result from the ordinary negligence of the Center.

The Center reserves the right to take photography and/or video of any/all programs and activities and use them for advertising and publicity purposes. I will not be compensated in any way for the use of this material. I hereby consent to the taking of such photography and/or video.

This informed Consent and Release of Liability shall be binding upon my heirs, spouse, or other next of kin, executor, administers and assigned.
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