Northeast Gymnastics Registration Form 2011-12

Please Print

Student's Name____________________________________

Male__________ Female__________

Nick Name_______________________ Age____________

Date of Birth______________________ Phone__________

Address__________________________________________

City_______________________ State________ Zip_______

E-Mail address_____________________________________

Family Doctor____________________ Phone____________

Insurance Carrier___________________________________

List any special problems, (Health or Physical) that the child may have that the instructor

should know about _____________________________________________________

In the event of an Emergency, if the Parent cannot be contacted we should notify...

Name_________________________ Phone______________

Parent's or Guardian's Name

Father_______________________

Firm Name________________________ Phone___________

Occupation_________________________________________

Mother_______________________

Firm Name________________________ Phone____________

Occupation___________________________________

I hereby apply to Northeast Institute of Gymnastics Inc. for instructions. If accepted, I agree

to pay all fees in advance and hold Northeast Institute and the staff harmless from any and

all claims of any nature. In case of emergency, if the parent or guardian, relative or personal

physician are not available, I authorize Chris Chakas or his representative to secure

emergency medical care.

Applicant's Signature___________________________________________________________

Parent/Guardian Signature_______________________________________________________

Date___________________

I (Parent/Guardian Signature)_________________________________________________

have read and understood the policies and procedures of Northeast Institute of Gymnastics Inc.

After reading the information and rules, I would like to enroll my child in Northeast Institute

of Gymnastics.

Class Choice:

Day________________ Time_____________________

 Once registration fee of $35.00 is received your child will be registered for the class. There will be

no formal notification. You will be notified if he class you request is not available. First Month's

tuition payment is welcome but not required until the child's first class.

How did you discover Northeast Gymnastics ?

Friend________ Paper________ Web Page________

other_______________________________________