Activity Participation Form

Gymfinity Children's Activity Center
6300 Nesbitt Road
Fitchburg, WI 53719
608-848-FLIP

Participant Information

First Name

Last Name

Sex

Birth Date

Choose your Activity

Household / Adult Primary Contact

Relationship to Participants:

First Name

Last Name

Address 1

Address 2

City

State

Zip

Phone

Cell Phone

Email Address

As a condition of participation for the student listed above in any programs conducted by Gymfinity Ltd. (d/b/a Gymfinity Gymnastics) I agree to waive any claim of bodily injury, or property damage

Agree

I understand the scope of this waiver includes my child, myself or any family member

Agree

I agree this waiver will be in effect every time we participate in a Gymfinity Program

Agree

If ineffective I agree to indemnify Gymfinity for any expenses resulting from our participation including but not limited to legal fees

Agree

AUTHORIZATHION OF MEDICAL CARE: In the case of illness or injury, if I cannot be reached, I authorize and desire medical care for my child at Gymfinity's descretion. I accept responsibility for any and all associated expenses

Agree

AUTHORIZATION OF LIKENESS RIGHTS: Gymfinity may take photographs, audio or video recordings of participants. I authorize use of and display likeness images of my child or myself for advertising or decorative purposes

Agree

I have read, understood and agree to all of the statements above. My checking here and the re-entry of my name below will constitute a legal signature.

Agree

Re-Enter Parent/Guardian name here

Should Gymfinity contact you regarding other programs or information?

Yes

No

Indicates Response Required


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