Registration Form 2007 - 2008

 

 
 

Classes Interested In:

   
 

Date of Classes:

   
 

Time of Classes:

   

 

Last Name(OF STUDENT HOUSEHOLD)

 

Home Phone (515)

 

Cell Phone #’S

 

Home Address

 

City

 

Zip

 

Mother’s Name

 

Work Phone

 

Employer

 

Father’s Name

 

Work Phone

 

E-mail address
(Newsletter will be sent monthly)

 

Person(s) responsible for payment
if different from above

 

Student  #1 - LAST NAME

 

FIRST NAME (they want to go by)

 

M/F

 

AGE    

 

Birth date

 

Grade (fall 2007)

 

Student  #2 - LAST NAME

 

FIRST NAME (they want to go by)

 

M/F

 

AGE

 

Birth date

 

Grade (fall 2007)

 

Student  #3 - LAST NAME

 

FIRST NAME (they want to go by)

 

M/F

 

AGE    

 

Birth date         

 

Grade (fall 2007)

 

AGE    

 

HOW DID YOU HEAR ABOUT US? (please circle)

PERFORMANCE       FRIEND       YELLOW PAGES       NEWSPAPER        DOOR HANGER        OTHER

 

 

 

2007-2008 Release Statement

 

 

 

PART 1: Release to allow Superstars to Render First Aid and/or seek Emergency Services in the absence of Parents or Guardians

 

 

 

I fully understand that Superstars staff members are not physicians or medical practitioners of any kind. With the above in mind, I hereby release the Superstars staff to render temporary first aid to my child or children in the event of any injury or illness, and if deemed necessary by the Superstars staff to call our doctor and seek medical help, including transportation by Superstars staff member and or its representatives, whether paid or volunteer, to any health care facility or hospital, or the calling of an ambulance for said child should the Superstars staff deem this to be necessary

 

 

 

PART 2: Agreement not to sue or cause litigation versus Superstars., its agents or employees

 

 

 

We, the staff of Superstars, recognize our obligation to make our students and their parents aware of the risks and hazards associated with the sport of gymnastics, twirling, tumbling, trampoline, cheerleading, dance, acrobatics, and/or specialized sports training. Students may suffer injuries, possibly minor, serious or catastrophic in nature. Gymnastics, Twirling, Tumbling, Cheerleading, Dance, Acrobatics, and/or Specialized Sports Training can be dangerous and can lead to injury or death!

Parents should make their children aware of the possibility of injury and encourage their children to follow all the safety rules and the coaches’ instructions.

Superstars, its coaches, teachers and other staff members, will not accept responsibility for injuries sustained by any student during the course of Gymnastics, Twirling, Tumbling, Trampolining, Acrobatics, Cheerleading, Dance, and/or Specialized Sports Training open workouts, or in the course of any exhibition, competition or clinic in which he or she may participate or while traveling to or from the event.

With the above in mind, and being fully aware of the risks and possibility of injury involved, I consent to have my child or children participate in the programs offered by Superstars and or its representatives whether paid or volunteer.

I also affirm that I now have and will continue to provide proper hospitalization, health and accident insurance coverage which I consider adequate for both my child’s protection and my own protection.

I also understand that it is the parents’ responsibility to warn the child about the dangers of gymnastics and injury. The parent should warn the child according to what the parent feels is appropriate. Superstars will only warn the child through “Safety Messages” and our teaching style and progressions.

I also give my permission to Superstars staff to give my child (ages 11 and older) Tylenol or ibuprofen if deemed necessary.

 

 

 

PART 3: I have read the policies, fees and payment plans. I agree to follow the rules as stated in the policies of the Superstars Performing Arts Academy. If I fail to follow the rules as stated I know that my child will be dropped from classes. I agree to make the payments required for my child(ren) to participate in the classes he/she/they are registered and all other fees and merchandise involved. I also agree to pay any late fees outlined in these policies, legal fees, mediation or court costs if the Superstars have to pursue payment of my account.

 

 

 

Parent or Guardian Signature

 

 

 

Date:

 

 

 

EMERGENCY CONTACT INFORMATION

 

 

 

Student Name(s):

 

 

 

In case of an emergency and the parent cannot be reached we need another person(s) to contact for your child. In case of a medical emergency the person should live in or close to your community.

 

 

 

Parents Cell Phone Numbers:

 

Secondary Contact Name:

 

Relationship:

 

Phone:

 

Secondary Contact Name:

 

Relationship:

 

Phone:

 

Doctor:

 

Hospital:

 

 

 

Is there any medical information we would need to give to medical personnel in case your child would not be able to speak? (i.e.: allergies, medications,etc)