Erie Gymnastics Center
                                 Main Mailing Office:  4725 Park Harbor Dr.
                                                    Erie, PA 16511
                                               Team Lightning Inc.
                                Phone: 814-898-2936 Fax: 814-899-7780
        2010 -2011 Registration Form
                                                                     Please Complete Both Pages 1 & 2

Section 1.  Family Information (Responsible Party)

Mother's Name: _________________ Father's Name: _________________ Last Name: ________________________

Street Address: _____________________________________ City: ______________ St: ______ Zip: ___________

Home Phone: (_____)________________ Cell Mom (_____)_______________ Cell Dad (_____)________________

Mom's Work Phone (_____)_______________ Occupation (optional) _____________________________________

Dad's Work Phone   (_____)_______________ Occupation (optional) _____________________________________

Email Address: ________________________________________________

Please fill out the following emergency information.  Who would we call if we can not reach either parent in an emergency?

Emergency Contact Name: ___________________________________ Phone Number (_____)__________________

Section 2.  Student Information (One form per child: each child is treated individually)

Gymnasts First Name: _________________ Last Name: ____________________________       Sex:   Male □     Female □

Birthday   _____/_____/_____  Current Age: _____    Health Issues/Allergies: ________________________________

School: __________________________ Grade: ______   Medical Insurance Carrier: ___________________________

How did you find out about Erie Gymnastics Center? (circle one)  Exhibition //  Parade  //  Radio  //  Television //  Web Search

     Newspaper  //  Phone Book  //  Drive-by  //  Flyer  //  Other ... ________________________  //  Friends Recommendation

If a freind recommended you or ad, which one specifically? _________________________________________

Purpose for gymnastics training? ____________________________  Child's Other activities _______________________

Any previous illness or injury we should know about? _____________________________________________________

Date of last physical: _____/_____/_____ Results ________________________________________________________

Child's T-Shirt Size (circle one)  CXS 2-4   //   CS 6-8   //   CM 10-12   //   CL 14-16   //   AS    //   AM    //   AL    //  AXL

Logo Type: (circle one)         Boy Logo      or Girl Logo

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3. Release Statement: - Part 1:  Release to allow EGC to render First Aid and/or seek Emergency Services in the absence of Parents or Guardians.  I fully understand that Team Lightning Inc. dba Erie Gymnastics Center hereby referred to as 'EGC' staff members are not Physicians or Medical practitioners of any kind.  With that in mind, I hereby release EGC Staff to render temporary First Aid to my child/children in the event of an injury or illness, and if deemed necessary by EGC to call Emergency Services to seek medical help, including transportation by EGC Staff, representatives or ambulance services to any Health Care facility for said child should EGC Staff deem this necessary.  I hold EGC harmless and not liable for any costs associated with medical treatment or transportation.
Part 2: Agreement not to sue or cause litigation versus Team Lightning Inc., its agents, employees, or volunteers.  We, the EGC Staff recognize our obligation to make students and their parents/guardians aware of the risks and hazards associated with the sport of gymnastics, tumbling, trampoline, cheerleading, dance, acrobatics, and/or any specialized sports training.  Students may suffer injuries, possibly minor, serious or catastrophic in nature.  Gymnastics, tumbling, trampoline, cheerleading, dance, acrobatics, and/or any specialized sports training can be dangerous and lead to injury or death!  Parents should make their child aware of the possibility of injury & encourage their children to follow all safety rules, practices, & instructions.  Team Lightning Inc., (dba Erie Gymnastics Center)- it coaches, instructors, Staff & volunteers, will not accept responsibility for any injuries sustained by the student during the course of any activity associated with Gymnastics, tumbling, trampoline, cheerleading, dance, acrobatics, and/or any specialized sports training, including clinics, exhibitions, competitions, nor any activity hosted by EGC, nor transit to or from.  With that in mind, and being fully aware of the inherent risks for injury/death involved, I consent to have my child/children participate in programs offered by Team Lightning Inc.  I also affirm that I now have and will continue to maintain proper hospitalization / health and accident insurance coverage which I consider adequate for both my child's and personal protection.  I also understand that it is the parent/guardians responsibility to warn the child about the dangers of participation and injury.  EGC will only warn the child through 'Safety Messages', teaching style & progressions.
Part 3:  EGC reserves the right to use my child's name, photographic image or video images for Promotional purposes.
   
X ______________________________________________________ < Signature  Date: _____/_____/_____  
Section 4. Financial Information: EGC Auto Draft/ Auto-Charge Application ** Required for Admission**  - Dear Valued Customer,  In order to better serve our clients, we require all member to secure payment with either an electronic Bank Withdrawal (ach), or Credit Card.  Our automatic bank withdrawal system is easy, safe & convenient.  You may pay your tuition in advance (7 business days prior to the first of each month) to avoid using the automatic payment system.  However you still must provide us with authorization to process your charges either banking or Credit Card in the event you fail to pay your bill on time.  Please refer to the any additional specifics in the "Parent / Gymnast Handbook".
     Please fill in all the required information and return along with a voided check (for bank withdraw) with this application.
                                Financially Responsible Party:

Last Name:____________________________ First Name:____________________ Middle Initial:__________

Address: ______________________________________ City: _____________ St: ________ Zip: __________

Phone: Day (______)____________________ Evening (______)___________________

Name of Bank/ Savings & Loan/ Credit Union: _____________________________________________

Circle one ---     Checking Account         //     Savings Account     //     Credit Card

Routing Number: ____________________________  Account Number ______________________________
or
Credit Card Number ________-________-________-________  Expiration Date ______-______
Authorization Agreement:  Team Lightning Inc. is hereby authorized to initiate withdrawals or draw by electronic funds transfer from the named checking/savings account or Credit Card, on or about the first business day of each month for the amount of services conducted by Team Lightning Inc.  In addition, the banking institution is authorized to charge to my/our checking/savings account the withdrawals initiated by Team Lightning Inc.  In the event I/we cancel this authorization, I/we may do so by providing written notice to Team Lightning Inc. which notice shall be effective within seven business days after receipt.  If my/our account does not have sufficient funds to cover the charge(s), I/we agree to pay a $25.00 fee for nonsufficient funds and late fees payable to Team Lightning Inc. (dba Erie Gymnastics Center.  I/we also agree to pay all legal fees associated with collection efforts including any Legal Fees.

X ______________________________________________________ < Signature  Date: _____/_____/_____  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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OFFICE USE ONLY:  Class Type: _____________  Day: ____________ Time: ________________ Price: _______________

     Application taken by: _____________________  Entered by: _________________  Date ____/_____/_____  Int. __________