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BISMARCK GYMNASTICS ACADEMY, INC.
3200 North 10th Street, Bismarck, ND 58503
701/258-8956
PLEASE PRINT ALL INFORMATION
GYMNAST_____________________________ circle one M/F BIRTHDATE____/____/_____
(first and last name)
2ND GYMNAST__________________________ circle one M/F BIRTHDATE____/____/_____
(first and last name)
3RD GYMNAST__________________________ circle one M/F BIRTHDATE____/____/_____
(first and last name)
4th GYMNAST___________________________ circle one M/F BIRTHDATE____/____/_____
(first and last name)
HOME PHONE___________________________CELL PHONE____________________________________
ADDRESS__________________________________CITY___________________ZIP CODE_____________
MAILING ADDRESS (if different)____________________________________________________________
EMAIL ADDRESS_________________________________________________________________________
FATHER_______________________________ADDRESS_________________________________________
(first and last name) (if different)
WORK PHONE______________ EMPLOYER____________________HOME PHONE_________________
(if different)
MOTHER______________________________ADDRESS_________________________________________
(first and last name) (if different)
WORK PHONE______________EMPLOYER____________________ HOME PHONE_________________
(if different)
RESPONSIBLE BILLING PARTY____________________________________________________________
EMERGENCY CONTACT OTHER THAN A PARENT (if possible)
NAME_____________________________________PHONE_______________________________________
HOSPITAL PREFERENCE__________________________________________________________________
PHYSICIAN'S NAME______________________________________________________________________
ANY SPECIAL PROBLEMS WE SHOULD BE AWARE OF?______________________________________
Where did you learn about the Bismarck Gymnastics Academy?
Park & Rec Brochure________ Television Ad________ Yellow Pages________
Birthday party ________ Friend ________ Other ________
****READ, SIGN AND DATE THE BACK PAGE OF THIS FORM.****
THANK YOU FOR PARTICIPATING IN OUR PROGRAM!!
CLUB WAIVER AND RELEASE FORM
I fully understand the Bismarck Gymnastics Academy staff members are not physicians or medical practitioners of any kind. With the above in mind, I release BGA staff to render temporary first aid to my child or children in the event of any injury or illness, and if deemed necessary by BGA staff to call our doctor and to seek medical help, including transportation by a BGA staff member and or it's representative whether paid or volunteer, to any health facility or hospital, or the calling of an ambulance for said child should the BGA staff deem this necessary.
Parent or Guardian Signature________________________________________Date______/______/______
WE; the staff of Bismarck Gymnastics Academy recognize our obligation to make our students and their parents aware of the risks associated with the sport of gymnastics, tumbling, cheerleading, and dance. Students may suffer injuries, possibly minor, serious, or catastrophic in nature. Gymnastics, tumbling, cheerleading can be dangerous and can lead to injury.
Parents should make their children aware of the possibility of injury and encourage their children to follow all the safety rules and the coaches' instructions.
Bismarck Gymnastics Academy, it's coaches and other staff members, will not accept responsibility for injuries sustained by any student during the course of gymnastics, tumbling, cheerleading, or dance instruction, or open workouts, or in the course of any exhibition, competition, or clinic in which he or she may participate or while traveling to or from the event.
With the above in mind, and being fully aware of the risks and possibility of injury involved, I consent to have my child or children participate in the programs offered by BGA. I, my executers, or other representatives, waive and release all rights and claims for damages that I or my child may have against BGA and or it's representatives whether paid or volunteer.
I also affirm that I now have and will continue to provide proper hospitalization, health, and accident insurance coverage which I consider adequate for both my child's protection and my own protection.
I also understand that it is the parent's responsibility to warn the child about the dangers of gymnastics injury. The parent should warn the child according to what the parent feels is appropriate. BGA will only warn through "Safety Messages" and teaching style and progressions.
Parent or Guardian Signature________________________________________Date______/______/______
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