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Student Information
Name: Sex: Age: DOB: ___/___/______
Parent's Names:
Address: City/Town ST Zip
Home Phone: Phone where parent can be reached DURING class:
Are there any medical conditions to which we should be alerted?
Primary Health Insurance:
Approved Drivers (other than parents)
name: phone:
name: phone:
name: phone:
Has this student ever been enrolled at East Bay before? Y / N If yes, how many years?_______
If your child were to appear in a group or individual photo taken on our premises are we free to use it for advertising purposes (brochure, web site, etc.)? YES / N0
Email address:
Class Information
First Choice* Class Level________________________ Day(s): Time(s):
Second Choice Class Level________________________ Day(s): Time(s):
* We will see you the first day of class.... We call ONLY if there is a problem supplying your first class choice!
Payment Information
Annual Family Registration Fee
$35.00
Tuition (Session payment required in full.) Fully refundable if your first class choice is not available.
$_______
Total Enclosed (Payment by check and US Mail is preferred)
$_______
Visa Number: Exp. Date:
Mastercard Number: Exp. Date:
Name on credit card:
Signature
Assumption of Risk, waiver of liability, medical authorization

As legal guardian of _______________________________________, I recognize that potentially severe injuries, including permanent paralysis or death can occur in sports or activities involving height or motion, including but not limited to gymnastics, tumbling, trampoline, dance, cheerleading and swimming. Being fully aware of these dangers, I voluntarily consent to the aforementioned child participating in any and all East Bay Gymanstics, Inc. programs, camps, and activities. I ACCEPT ALL RISKS associated with that participation.

In consideration for allowing my chld to use these facilities, I, on my own behalf and on the behalf of my child, hereby COVENANT NOT TO SUE and FOREVER RELEASE East Bay Gymnastics, Inc. its officers, directors, administrators, employees or agents from all liability for any and all damages or injuries suffered by my child while under the instruction, supervision, or control of East Bay Gymnastics, Inc.

In the event of an accident or emergency I would like my above mentioned child to be taken to a hospital via ambulance for medical treatment and I hold East Bay Gymnastics, Inc. and its representatitve harmless int heir execution of this action. I have read and understand this ASSUMPTION OF RISK and WAIVER OF LIABILITY and MEDICAL AUTHORIZATION and I VOLUNTARILY affix my name in agreement.
Parent or Legal Guardian's Signature: Date: