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Carter's Gymnastics Registration Form

Student’s Name________________________________________________________

Home Phone #____________________________

Address___________________________________________________________ 

Neighborhood____________________________

City________________________________ County______________________ 

State_______ Zip Code__________________________

Sex_____________ Date of Birth________________________  Age_______ 

Nickname_______________________________________ 

Home Fax #_____________________________

Student Email Address_______________________________________________

Sign Up Date___________________ Class _______________________________ 
Class Day(s)/Time_____________________________

School____________________________________________________________ 

Grade________ # of children in gym_________

Mother’s Name______________________________________________________ 

Work Phone #_______________________________

Occupation_____________________________________________

Title_____________________________________________________ 

Company Name____________________________________________________ 

Work Fax #__________________________________

Mobile Phone #________________________________ 

Mother’s Email Address____________________________________________

Father’s Name___________________________________________________ 

Work Phone #________________________________

Occupation_____________________________________________

Title_____________________________________________________ 

Company Name__________________________________________________ 

Work Fax #__________________________________

Mobile Phone #________________________________ 

Father’s Email Address____________________________________________

Emergency Contact________________________________ 

Phone #__________________________ Relationship___________________

Alternate Contact__________________________________ 

Phone #__________________________ Relationship____________________

Family Physician______________________________________________________ 

Phone #__________________________ 

Health Insurance Company________________________ 

Health Insurance Policy #___________________________________________

Restrictions/Medical Conditions Affecting Participation

_______________________________________________________________

Emergency Medical Authorization/Waiver
 If I cannot be reached in the event of an accident or emergency, 
while the above is under the care and supervision of Carter's Gymnastics, 
I hereby authorize and give permission to their staff/assigns to undertake and employ emergency first aid, 
emergency transportation, obtain emergency medical treatment, 
and act in my stead to follow such procedures as necessary to admit and treat any emergency condition, 
at any hospital, if it is deemed necessary. 
I attest that I have current and valid medical insurance and will be 
financially responsible for any and all emergency medical expenses. 
Carter's Gymnastics has my full permission to act as a temporary guardian in an 
emergency situation. 
By signing this, I agree to hold harmless Carter's Gymnastics and any hospital 
from any liability for commencing emergency medical treatment with any more 
consent than hereby given. 
For and in consideration of my/our voluntary participation in the gymnastics 
or related programs of Carter's Gymnastics, 
recognizing and attesting that all due legal warnings have been given, 
including the possibility of temporary or permanent injury, broken bones, 
catastrophic injury, death, paralysis, or neck or back injury, ligament or tendon damage, 
having determined that appropriate precautions are and will be taken in connection therewith, 
recognizing and personally attesting that gymnastics and related activities should be 
and are legally defined as inherently dangerous sport and activities, 
I/we hereby assume all risks, waive and forever release any and all rights and claims 
for personal injuries, mental and emotional suffering, property damages, 
punitive damages and loss of services which I/we may have, 
now or in the future against Carter's Gymnastics, its officers, 
assigns, agents, employees, landlords, and successors. 
This waiver shall be binding on my/our family, heirs, executors, administrators and assigns. 
I/we certify that the participant has had a recent physical exam (within the last year), 
is physically able to participate and presents themselves, physically and emotionally, 
fully ready to participate in all ways and with a full understanding of the rules,
regulations and policies of Carter's Gymnastics.
 

Gymnast’s Signature____________________________________________ 
 

Parent/Guardian Signature________________________________________