10.0 Academy

181 Great Road, Stow MA 01775

Class Registration Form

Family’s LAST NAME______________________________________ Home Phone # (          )______-__________

Address__________________________________________ Town_________________ Zip_________________

Email_________________________________________________Do you want to receive updates of events?  Yes / No

Students Name

Age

Date of Birth

Session

#

Class

Day

Class

Time

Session

$

6 Sessions

@

Annual Family Registration Fee: Due Annually Sept-August

Discounts: 2nd child -10%, 3rd child -20%, 4th child FREE

$25.00

$

Full Season Payment Option: 6 auto-debits: Card will automatically be charged for each tuition cycle.

Full Season payment option is only available when a credit card is placed on file.

____intl  M/C/Visa /Dis #____________________________________________Exp Date______/______Zip Code_________

Mother’s Name______________________________________ Cell / Work Phone # (             )________-___________

Father’s Name______________________________________ Cell / Work Phone # (             )________-___________

Please list any special needs, allergies, medications, learning disabilities or any other information we may need to make

your child’s experience a positive one._________________________________________________________________

In the event of an emergency Parents will be notified first.  If unable to contact you, please list additional emergency contract.

Name______________________________ Relationship_________________ Phone # (             )________-___________

AUTHORIZATION OF PARTICIPATION: I give all members of my family permission to participate in any program(s), camps, and special events of 10.0 Academy.  I hereby certify that to the best of my knowledge my children/family are in sufficient physical condition to participate safely in all activities and I am willing to provide a Physician’s certificate if so desired by the Director.  I understand that it is the expressed intent of 10.0 Academy to provide for the safety and protection of my children/family and in consideration for allowing my family to use these facilities, I hereby forever release 10.0 Academy, it’s officers, employees, teachers, and coaches form all liability, for any and all damages and injuries suffered by my children/family while under the instruction, supervision of 10.0 Academy.  I recognize that participation in any sport, including gymnastics, which involves height, motion, and rotation that injury can occur.  This includes severe injuries including permanent paralysis or even death.  I authorize 10.0 Academy to seek medical attention at the nearest Medical Facility in case of emergency.  I hereby give consent for 10.0 Academy to use our photographs and likeness to be used in its publications, website and ads. I release them from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian.  No refunds or credits will be given for absences. Please dress for gymnastics activities (No jeans, dresses, or tights).

ENROLLMENT AGREEMENT AND REFUND POLICIES: This will secure a place for your child(ren) in a limited class for the session or full season.  Payments accepted by Cash, Check, Mastercard, Visa, or Discover.  Your tuition, minus a $25 processing fee will be refunded with written notice of withdrawal given at least 48 hours prior to the start of your first scheduled session/class.  50% of your tuition, minus a $25 processing fee, will be refunded with written notice of withdrawal given prior to the start of second class.  There are no refunds or credits given after our second scheduled class.  A $5 late fee will be charged the 7th of each month to all outstanding accounts.  A surcharge of $25 will be charged for any returned check.  10.0 Academy reserves the right to cancel any class due to lack of enrollment.  Make-ups are permitted on a space availability basis only, and must be scheduled ahead of time with the office.  No refunds or credits will be given for missed classes, nor are they transferable to other persons or succeeding sessions.  This is an acknowledgement of risk and waiver of liability, having been read thoroughly and understood completely, signed voluntarily as to it content and intent.  I hereby execute and deliver this waiver and release form, to permit my child(ren)s participation in the program(s).  I have read and agree to the enrollment conditions, as stated above.

Parent / Guardian Signature:___________________________________________ Date___________