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Joe's Planet Funastics
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803-549-7166 jplanetfun@sc.rr.com
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Joe's Planet Funastics Form
**This form must be filled out and signed for your child to participate in gymnastics classes or camps.**
Student's Name:________________________________ Phone #:___________
Address:_______________________________________City:___________Zip:___________
DOB:_________________Age:______________Sex:_________________
Mother's Name______________________________
Mother's Work #:___________________________
Father's Name:_____________________________
Father's Work #:___________________________
Class (School/Daycare/Center)Location____________________________________________
Student's Medical Information
Allergies (drugs, food etc.) Yes__No__
Seizures or Convulsions Yes__ No___
Serious Injury (fractures or broken bones) Yes__ No__
Mental Disorders Yes___ No___
Birth Deformities (short legs, arm, etc.) Yes___ No___ Contacts or Glasses Yes___ No___
Known Past Illnesses of More than One Week's Duration Yes___ No___
If you answered Yes to any of the above questions, please explain below:
___________________________________________________________________
____________________________________________________________________
In the event of an emergency, if we were unable to reach you, whom would you like us to contact?
Name:________________________ Relationship:_________________
Phone #'s ____________________________________________
Release of Liability and Assumption of Risk
In consideration of the opportunity given to my child to participate in gymnastics instruction classes,
in connection with my enrollment of my child as a student in Joe's Planet Funastics,
and in recognizing that gymnastics is a sport involving height and motion,
and like any other sport therin lies the possiblity of accidental injury,
I hereby knowingly, freely and voluntarily waive right of cause of action of any kind whatsover
arising as the result of such acticity by the child either before, during or after
participating in his or her scheduled class, make-up or any other special event,
from which any liability may or could accrue to Joe's Planet Funastics, it's owners,
agents, or employees and instructors. I also give permission for images of my child
to be used by Joe's Planet Funastics for promtional purposes.
I hereby certify that I have read the above and foregoing release and execute same this ___________ day of _________, 20___.
Signature of Parent or Legal Guardian __________________________________________________________
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