Академический Документы
Профессиональный Документы
Культура Документы
GCG#__________________
Class___________________
Session/Start Date:________
Fee:____________________
Card on File _____________
In Contacts ______________
Account Name________________
Payment/session____ monthly_____
MEDICAL INFORMATION
Please provide additional details on any medic alert situations (severe allergy, asthma,
disabilityetc):________________________________________________________________
____________________________________________________________________________
Epi-Pen? ____________________ Other? _________________________________________
Health Card Number ______________________________ Expiry _______________________
Family Doctor ____________________________________ Phone ______________________
Mothers Occupation_______________________ Fathers Occupation ___________________
Email Address:_______________________________________________________________
MEDIA RELEASE
Kippers will sometimes take pictures / video during classes for promotional and educational purposes.
Kippers has a weekly newspaper column which may feature different classes at any given time.
I, ____________________________, give permission for Kippers to use pictures / footage and the name
of my child (please print) _______________________________________________ for promotional use.
Signed: ________________________________________ Date: _______________________________
Waiver / Parent Signature
It must be understood that there is an inherent risk in any active program and we, Kippers School of
Gymnastics, staff, Executive and Coaches are in no way responsible for damage to or loss of property; or
injury to participants, unless proven negligent. We, therefore, ask you to release, absolve, indemnify and
hold harmless the Kippers School of Gymnastics, staff, Executive, Coaches, organizers and sponsors in
the case of injury to your child.
Parent / Guardian Signature: ____________________________________________________________
Date: ____________________________
All information provided to our organization is kept in strict confidence