Parent/Guardian Name___________________________________________  Today's Date______________________
(Adult Registration) Birthday_______________________  Family e-mail ____________________________________
Children:
1.__________________________________ Birthday_________ Age____ Grade____ School_____________________

Medications, conditions, injuries or surgeries____________________________________________________________

2.__________________________________ Birthday_________ Age____ Grade____ School_____________________

Medications, conditions, injuries or surgeries____________________________________________________________

3.__________________________________ Birthday_________ Age____ Grade____ School_____________________

Medications, conditions, injuries or surgeries____________________________________________________________

4.__________________________________ Birthday_________ Age____ Grade____ School_____________________

Medications, conditions, injuries or surgeries_____________________________________________________________
5.__________________________________ Birthday_________ Age____ Grade____ School_____________________

Medications, conditions, injuries or surgeries_____________________________________________________________
6.__________________________________ Birthday_________ Age____ Grade____ School_____________________

Medications, conditions, injuries or surgeries____________________________________________________________

Address_______________________________________ City___________________ State/Zip____________

Home Phone__________________________ Work Phone______________________

Mom Cell Phone_______________________ Dad Cell Phone____________________
Emergency Contact Information:

Name_________________________________ Phone_____________________ Relationship___________________

How did you hear about Leaps & Bounds?____________________________________

Please list previous gymnastics, dance, cheer or fitness locations__________________________________
Liability Waiver & Disclaimer:
As with any physical activity it is best to consult a doctor before beginning any activities offered at Leaps & Bounds. By registering yourself or your child(ren) for any activities at Leaps & Bounds Gymnastics & dance you ensure that you or your child(ren) is /are physically able to withstand the activities involved and consent to participation in any and all activities offered at Leaps & Bounds Gymnastics & Dance.
Signature_______________________________________ Date__________________

I fully understand that the staff at Leaps & Bounds Gymnastics & Dance are not physicians or medical practitioners of any kind. I hereby release the staff, sub-contractor, or representative of Leaps & Bounds Gymnastics & Dance to render emergency first aid to myself or my child in the event of any injury or illness, and if deemed necessary to call an ambulance, which I agree to pay for. I agree to provide health insurance for myself and/or the above listed minor(s) child(ren) and/or guarantee payment of any medical expenses incurred as a result of training, performing, or participation in activities with Leaps & Bounds Gymnastics & Dance.
Signature_______________________________________ Date____________________

I am fully aware of the inherent risks involved in gymnastics, dance, cheerleading and fitness participation including injury, paralysis, or even death and herby release from liability and hold harmless Leaps & Bounds Gymnastics & Dance, it's employees, volunteers, sub-contractors, and representatives.
Signature______________________________________ Date_____________________

Photo/Video Release:
I hereby give my consent for Leaps & Bounds Gymnastics & Dance to use any photos or videos taken of myself or my minor child(ren) for the use of advertising or any other promotional use. I understand that I/we will not be compensated in any way for such use.
Signature______________________________________ Date_____________________

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