Youth Camp Health Exam Form
(CLICK ABOVE TO PULL UP PRINTABLE FORM)

Date of Registration
Class(es)
 		Day/Time
Email Address
Student's Name
 		Birthday
Address
 		Town
Zipcode
Home Phone
Mother's Name
 Work Phone
Father's Name
 Work Phone
Emergency Contact
 Relationship/Phone

Payment Options
Full Session
Payment Plan (pay@office)
Automatic Charge
       Full Session Fee
       Payment Plan Fees

POOL MEMBERSHIP
Current Member    Card #
Flipper Fee
Single Adult (18 & older)
Silver Card     Silver Senior (62 & older)
Gold Card     Gold Senior (62 & older)

Visa or Master Card number (required)
 Personal Name on Charge Card
Expiration Date

Appropriate registration fees must accompany each registration / release form ($40 for first child; $20 for each additional child and/or appropriate pool membership) as well as first scheduled class fee.

Make checks payable to: Gymnastics World
18 Knollwood Dr.
Clinton, CT 06413

Accounts not paid by due date will be subject to a $10 late fee. A $15 fee will be charged for all returned checks.
Monetary reimbursements are not given for classes missed or sessions not completed. Make-up times are provided.
My child has had a recent exam and is physically able to participate in a physical exercise program. In the event emergency medical treatment is required, Gymnastics World is granted permission to contact the doctor indicated below to provide the treatment and / or give instructions for treatment
Doctor's Name
 Phone
In the event the doctor cannot be contacted immediately, Gymnastics World has permission to arrange for medical treatment through whatever medical facility is available. If there are additional instructions please indicate below.
Please list any specific medical conditions that we should be aware of and / or any allergies or dietary restrictions.

I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis, and even death, as well as other damages and losses associated with participation in gymnastics activities and events. I agree to indemnify and hold Gymnastics World of Clinton, Inc. its employees and officers harmless from and against any and all liability for any injury which may be suffered by the aforementioned individual arising out of or in any way connected with participation in this activity.

As legal parent of guardian of this athlete, I hereby verify by selecting the button below that I fully understand and accept each of the conditions for permitting my child to participate in classes, events, competitions, and activities conducted by Gymnastics World of Clinton, Inc.

Email us at weflip@gymnastics-world.com