EmailMe Form - Permission to Participate Waiver

Child's Name *

First Last

Date of Birth *

MM / DD / YYYY

Any Allergies *

Enter NONE or list any allergies or special information

Home Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Health Ins. *

Health Insurance Carrier

Parent's Name *

First Last

Mother's Name or Main Guardian's Name

Parent's Cell # *

### - ### - ####

Mother's Cell Phone or Main Guardian's Cell Phone

Family Email *

Mother's e-mail or Main Guardian's e-mail

Emergency Name *

First Last

Emergency Contact other than Parent or Guardian

Emergency # *

### - ### - ####

Emergency Phone Number other than Parent or Guardian

Special Notes

Let us know of any special information or request.

RULES/POLICIES, WAIVER/RELEASE & ACKOWLEDGEMENT:

Read below and check marked boxes to confirm.

Rules/Policies *

I understand the Rules/Policies information.

CLOSURES: The gym may be closed for holidays or due to inclement weather. Call (914)238-4967 or visit our website for closure details and updates at www.worldcupgymnastics.com.

REFUNDS/CREDITS: Refunds will not be given for missed classes with less than 48 hours notice.

WHILE AT WORLD CUP GYMNASTICS: Parents and non-participating siblings are not allowed on the gym floor, except where required by the class description. Spectators may observe the class from hallways or the balcony. Do not call out or distract your child during their class. No child under the age of 12 may be left unattended on the premises, and children must be supervised at all times. Have your children obey the Gym Rules and Policies at all times. World Cup is not responsible for any lost or stolen items. Valuable items may be left with the front desk.

Waiver/Release *

I consent to the Waiver/Release information.

WAIVER: World Cup and its staff recognize our obligation to make our clients aware of the risks and hazards associated with the sport of gymnastics, tumbling, trampoline, cheerleading, Romperee, etc. World Cup Gymnastics and its staff will not accept responsibility for injuries sustained by any child, parent and/or caregiver during the course of any gymnastics activities and/or while arriving or departing or waiting anywhere on World Cup Gymnastics premises. Parents and/or caregivers should be aware of, and educate their children about the possibility of injury. Parents and/or caregivers should also encourage their children to follow all safety guidelines and World Cup staff instructions. Gymnastics can be dangerous and lead to injury. Students, parents and/or caregivers may suffer injuries, possibly minor, serious or catastrophic in nature.

Therefore, being fully aware of the risks and possibility of injury involved, I consent to have my child and/or myself participate in the programs offered by World Cup Gymnastics. I waive and release all rights and claims for damages that I or my child may have against World Cup Gymnastics and/or its representatives and staff, whether paid or volunteer. With this in mind, in the event of an injury or illness to my child or myself, and with the knowledge that World Cup staff members are not physicians or medical practitioners of any kind, I consent to the administration of temporary first aid to me and/or my child by World Cup staff if they deem necessary, contacting a doctor and/or seeking medical help, transportation by a World Cup staff member and/or its representatives, whether paid or volunteer, to any health care facility or hospital, calling 911 and/or an ambulance, etc. 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 and/or my own protection. I also understand that it is my responsibility to continually remind my child about the dangers of gymnastics, tumbling, trampoline, cheerleading, Romperee, etc. injury. World Cup Gymnastics staff members will continually remind the children, parents and/or caregivers of safety guidelines during our programs, as well as post signs throughout the premises.

PHOTO RELEASE: I authorize that World Cup Enterprises LLC has the right to use all photographs or videos taken of my child or children during camp, classes, practices, field trips, etc. for advertising or promotional materials, or on its website.

Acknowledgement *

I accept World Cup's terms and conditions.

I accept World Cup's Rules/Policies, Waiver/Release & allow my payment to be processed by World Cup administration.

Submission Date *

MM / DD / YYYY

Enter the date you submit this Permission to Participate Waiver.

Review all information and make any necessary changes.

Make sure all information is correct before processing registration form.