Child’s Name_______________________________________________Age_________Birthday________________________

Child’s Address____________________________________________________City___________________Zip___________

Does the child have any limitations/disabilities/injuries?  Circle   YES  or NO and describe on second page.

Mother’s Name___________________________________________Employer______________________________________

   Home Phone__________________Work________________Cell________________Drivers  Lic. #____________________

Father’s Name___________________________________________ Employer______________________________________

   Home Phone________________Work______________Cell_______________Drivers  Lic. #_________________________

Billing Address (if different than child's) ______________________________________________________________________

City____________________________________________________________State_________Zip_____________________

E-mail Address________________________________________________________________________________________

Emergency Contact (if parent not available):__________________________________________________________________

Relationship_________________________________________________Phone____________________________________

Referred By: _____________________________________________________(Used to credit a referring member if applicable)

Waiver for Participant and Parent

Participant has elected to take part in certain recreational activities. In consideration for and as a condition of such participation,

participant agrees to assume all risk involved with participation and agrees to hold Pacific Coast Gymnastics Center, and its

instructors and employees, harmless from all suits, claims, or demands of every kind and character arising out of or in connection

with the undersigned as a participant in said recreational program. Participant further releases Pacific Coast Gymnastics Center,

its instructors, and employees, from all suits claims or demands of every kind and character which participant or participant’s

successors or assigns shall or may have arising out of or by reason of or in connection with the course of instruction and activities

contemplated in the program. It is understood that participation in this activity could result in serious injury and/or death. It is

declared that said participant is physically fit to participate in the program and is in good physical condition. I hereby grant

permission to Pacific Coast Gymnastics Center to use images of my child on its World Wide Web site (www.pcgymnastics.com)

or in other official printed publications without further consideration, and I acknowledge their right to crop or treat the photograph at

their discretion. I also acknowledge that they may choose not to use the photo at this time, but may do so at their own discretion at a

later date. I also understand that once the image is posted on the web site, the image can be downloaded by any computer user.

Therefore, I agree to indemnify and hold harmless from any claims against the following: Pacific Coast Gymnastics Center and

Anne Flores, owner. Pacific Coast Gymnastics Center reserves the right to discontinue use of photos without notice.

Parent/Guardian Signature________________________________________       Date__________________________

IT IS MANDATORY THAT YOU REPORT ANY MAJOR NECK, BACK OR OTHER INJURIES THAT PARTICIPANT

HAS HAD.

Medical History:

Family Physician / Phone_________________________________________________________________________________

Date of Last Physical Exam_______________________________________________________________________________

Dates and Types of Recent Injuries Requiring Medical Attention____________________________________________________

Attending Physician for each injury__________________________________________________________________________

Does the Child Have any Limitations/Disabilities? ______________________________________________________________.

List Current Insurance Carrier______________________________________________________________________________

Policy Number_________________________________________________________________________________________

I understand my insurance company is responsible for my child(ren) while participating in activities at PCGC.

___________________________________________________________________________________

Signature                                                               Date

In the event of an emergency such as illness or injury, the parents of the student will be called first. If parents are not available, then

the emergency contact will be called. If neither is available the child will be taken to the nearest emergency room.

We authorize Pacific Coast Gymnastics Center officials or staff to arrange for such transportation and consent to any x-ray examination,

anesthetic, medical or surgical diagnosis or treatment or hospital care which is deemed advisable by, and is to be rendered under

the general or special supervision of, any physician or surgeon licensed under the provision of the medical practice act, whether

such diagnosis or treatment is rendered at the physician’s office or at the hospital. This authorization is given pursuant to provisions

of Section 25.8 of the Civil Code of California.

Release

We will in no way hold Pacific Coast Gymnastics Center officials or staff responsible for any illness, accident, or injury, which might

occur during the student’s participation at Pacific Coast Gymnastics.

Parent/Guardian________________________________________________     Date_________________________________

                          Office Use only

Trial Date Only: _______________

Trial Class: __________________

Enroll  Date: __________________

Reg Fee: ____________________

Tuition Amount: _______________

Class Chosen:________________

8981 La Linia, Suite A

Atascadero, CA  93422

Phone:  805-466-1483  Fax:  805-466-1490

www.pcgymnastics.com

Liability Waiver & Enrollment Form