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Activity Participation Form
Gymfinity Children's Activity Center
6300 Nesbitt Road
Fitchburg, WI 53719
608-848-FLIP
Participant Information
First Name
Last Name
Sex
M
F
Birth Date
Choose your Activity
*
Open Gym
Field Trip
Birthday Party
Parent's Night Out
Special Event
Household / Adult Primary Contact
Relationship to Participants:
*
Self
Mother
Father
Guardian
Other
Other
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
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