Registration & Release Form RegistrationFirst Child's Name First Last GenderMaleFemaleBirth Date Date Format: MM slash DD slash YYYY Second Child's Name First Last GenderMaleFemaleBirth Date Date Format: MM slash DD slash YYYY Third Child's Name First Last GenderMaleFemaleBirth Date Date Format: MM slash DD slash YYYY Mother's Full Name First Last Home PhoneMobile PhoneFather's Full Name First Last Home PhoneMobile PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Emergency Contact First Last PhoneEmail Insurance CarrierDid a gymNation friend refer you to the program?YesNoName of Friend First Last TuitionChild's Name First Last First Program/Day/CostSecond Program/Day/CostTotalChild's Name First Last First Program/Day/CostSecond Program/Day/CostTotalChild's Name First Last First Program/Day/CostSecond Program/Day/CostTotalAnnual Registration Fee $35 (First Child) $25 (Second Child) $60 (Family) + Annual Registration - First Child+ Annual Registration - Second Child+ Annual Registration - FamilyGrand TotalPlease read this Liability Release Form carefully and sign as indicated. In consideration of allowing the previously-declared participant(s) to begin participation in gymNation activities, while on the premises and property of said facility, the undersigned, for themselves, and/or being the legal and acting guardian of participant, acting for themselves and on behalf of the participant, release and hold harmless gymNation, its owners, officers, employees, and agents of and from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the under-signed, while in or upon the premises upon which gymNation is conducted, or any premises under the control and supervision of gymNation, its owners, officers, employees, or agents or in route to or from any of said premises, or while at any premises or place when activities sponsored by or participated in by gymNation, its owners, officers, agents, or employees. Assumption of Risk Participation in physical activities can involve motion, rotation, and height in a unique environment and as such carries with it a certain assumption of risk. The undersigned and the participant(s) choose to voluntarily enter upon said premises under the control of said corporation, knowing their present condition and knowing that said condition may become more hazardous and dangerous during the time the participant or the undersigned is upon said premises. The undersigned and the participant(s) voluntarily assume any and all risks of loss, damage, or injury that may be sustained by the participant(s) and/or the undersigned or any property owner by them while on or upon said premises described above. The corporation may but shall not be obliged to carry insurance on the participant(s), and the existence of insurance shall not change, alter, or increase the liability of the corporation to the participant and the undersigned or affect the terms of this Release. In signing this Release, the undersigned acknowledges: That he/she has read thoroughly and understands completely, the terms of Registration and Release and signs it voluntarily. That the undersigned signing either for themselves, or as Legal Guardian is, in fact, the true and legal guardian and has the consent of the participant. Tuition is priced on a year round basis and is charged monthly, regardless of the number of weeks in any given month. Months are not prorated for absences, holidays, school vacation weeks or "short" months. Withdrawal From Class: In writing. If you wish to withdraw from class, it must be done by the 15th of the prior month. Withdrawal forms are available at the front desk. Annual Registration Fee: Your annual registration fee will be automatically charged to your account on file on the first business day of your anniversary month. Renewal Date: The only method of payment accepted is an automatic charge from a credit card (Visa or MasterCard) or debit card to be drawn on the 1st of every month. A late fee of $20.00 will be assessed for declined credit cards not rectified by the 7th of the month. Students are not allowed to participate in class until all financial obligations are fulfilled prior to class.Parent/Guardian Signature*I have read and agree to the above terms and policies.Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.