GYMNASIANA
REGISTRATION
Name ______________________________________Phone _________________________
(Student's Name)
Address____________________________________________________________________
(Number and Street)
____________________________________________________________________
(City and Zip Code)
Date of Birth ___________________________
IMPORTANT:
FULL MONTHLY PAYMENTS MUST BE MADE ON OR BEFORE THE 10TH OF THE MONTH
STATEMENT OF
LIABIALTY:
WE UNDERSTAND THE FOLLOWING: GYMNASIANA WILL NOT BE LIABLE FOR INJURIES
OCURRING FROM
PREVIOUS SICKNESS OR ACCIDENTS.
I, ___________________________, AM IN GOOD HEALTH AT THIS TIME AND HAVE NO PREVIOUS ILLNESS OR
INJURY WHICH WOULD BE AFFECTED BY PARTICIPATION IN THIS PROGRAM.
________________________________________
_________________________
SIGNATURE OF PARENT OR GUARDIAN
DATE
MOTHER'S NAME ___________________________________
______________________________
(Please
Print)
(Occupation)
FATHER'S NAME ____________________________________
______________________________
(Please
Print) (Occupation)
NAME OF INSURANCE POLICY ___________________________________
EMERGENCY TELEPHONE NUMBER
______________________________
TIME & DAY OF CLASS __________________________________________
EMAIL ________________________________________________________
_____________________________________________________________________________________________