2011 Registration Form
Please type your information in the form below. Print, sign, and bring into the Klub.
Click Here or at the bottom of form to Print.

Student’s Information:
Student #1

Student’s First Name:		Last Name:
Student Gender: Female Male Birth Date:
Child's School:		Current Grade:

Does your child have any physical/social/emotional issues or allergies about which we need to know?
	Yes		No

If yes, please explain
Name of Pediatrician Phone
Name of Medical Insurance Carrier Policy #

Student #2

Student’s First Name:		Last Name:
Student Gender: Female Male Birth Date:
Child's School:		Current Grade:

Does your child have any physical/social/emotional issues or allergies about which we need to know?
	Yes		No

If yes, please explain
Name of Pediatrician Phone
Name of Medical Insurance Carrier Policy #

Student #3

Student’s First Name:		Last Name:
Student Gender: Female Male Birth Date:
Child's School:		Current Grade:

Does your child have any physical/social/emotional issues or allergies about which we need to know?
	Yes		No

If yes, please explain
Name of Pediatrician Phone
Name of Medical Insurance Carrier Policy #

Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Release of Liability
As the legal parent or guardian, I recognize the potential for injuries which can occur in gymnastics and activities involving movement, trampoline usage and exercise. I understand that gymnastics is a dangerous activity that can cause catastrophic injury, paralysis or even death from improper conduct of the activities. I hereby consent for myself and/or the above person participating in activities on equipment owned and/or used by The Klub, Inc. and herby agree that I, for myself, child(ren) adopted or otherwise, my heir and executors, waive and release any and all rights and claims for damages that I and/or the above at any time against The Klub, Inc., or its agents, owners, operators and representatives for any injury or damages in connection with my association with or entry in gymnastics or other activities sponsored by The Klub, Inc.

Photography Release
The Klub Gymnastics would like to feature photographs of our students on our site at www.theklubgym.com. These photographs may also be used in other publications such as advertising, brochures, newsletters and other promotional material. The photographs will be used as described and, as such, your child’s identity may be viewed by other students, parents, staff, and the public who may visit the web site or other promotional material.

If you agree to give permission to have your child’s image used, please indicate your agreement and initial below. By initialing, you irrevocably consent to the use and reproduction of photographs by The Klub Gymnastics, and represent that you are the parent or legal guardian of the child, with authority to execute this release form. In addition, you give consent for the images to be used as described above, without restrictions to alterations and without compensation to you or those under your parental care or guardianship. You also agree that the photographs and website or other material are the sole property of The Klub Gymnastics. Parents or legal guardians further agree to waive any and all claims against The Klub, Inc. and/or its officers, agents or employees arising from, or relating to the use or reproduction of the photographs by The Klub Gymnastics.

Medical Emergencies
The undersigned gives permission to The Klub inc., its owners and operators to seek medical treatment for the participant in the event if they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or condition and/or declare the participant to be in good physical and mental health. I request that our doctor/physician

be called and that my child be transported to the nearest hospital.

Please initial here:

Payment Information
Tuition is due upon receipt. Tuition not paid within the first week may result in the student not being allowed to attend class. There is a $25.00 returned check charge for any checks returned by the bank. Payment is required in full at the time of registration. Our 100% money back guarantee is for families new to The Klub Gymnastics who requests the refund in writing within 4 weeks of registering for classes. The refund is for the remaining tuition only. The membership fee is not refundable. Tuition pays for your child's spot in class regardless of actual attendance.

Make-Up Classes
There will be no credits issued for missed classes. Make-up classes will available on a first come, first serve basis. Make-up classes need to be completed within a 60 day period. Canceled make-ups require a 24 hour notice. If not, the make-up will be forfeited. Make-ups are only for active students.

Refund Policy
The Klub Gymnastics requires that we receive written notification (letter or email) by the 25th of the month to be removed from automatic payment for the following month. If we do not receive written notice, the first class will be charged to your account and will become non-refundable. The remaining tuition can be credited or refunded. Refunds to your credit card will post to your account within 10 -14 business days. No refunds or credits will be given after the first week of the session.

Parking

The parking lot is reserved for JCC drop off and pick up during the hours of 8:30am – 9:30am and 2:30pm – 3:15pm. Please DO NOT use the parking lot between those hours.

I have read the RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.

Parent’s / Guardian Signature________________________________ Date___________________

The Klub Gymnastics • 1110 Bates Ave • Silver Lake • CA • 90029
323.662.KLUB - phone
323.664.KLUB - fax

www.theklubgym.com

Credit Card Automatic Payment Authorization Form
Please type your information in the form below. Print, sign, and bring into the Klub.
Click Here or at the bottom of form to Print.

Drop off Form at The Klub Gymnastics Office or Fax to 323.664.KLUB (5582)
The Klub Gymnastics · 1110 Bates Ave · Silver Lake, CA 90029 · 323.662.KLUB (5582)