10.0 ACADEMY
181 Great Rd. Stow MA 01775
Gymnastics Class Registration Form
Family's LAST NAME ______________________________________Home Phone # ( ) _______ - _________
Address ____________________________________________________Town _______________Zip _______________
Email :____________________________________ SESSION: I II III IV (summer)
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Birth Date |
Class: Day/Time |
Single Session |
Full Season |
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Annual Family Registration Fee - Due Annually Sept-August (2nd child (-10 %) ,3rd child (-20%), 4th child (-30%), 5th child FREE! ) |
$15.00 |
$ |
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Full Season Payment Options: 3 auto-debits / 6 auto-debits : Please debit my credit card for each tuition cycle.
___intl M/C / Visa / Discover # _________-_________-_________-_________ Exp Date _____/_____Zip Code __________
Mother's Name ______________________________ Cell / Work Phone # ______/_________________ ext. ______
Father's Name ______________________________ Cell / Work Phone # ______/_________________ ext. ______
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 locate you, please list additional emergency contact.
Name _____________________________________ Relationship ______________ Phone # ( ) _____ - _________
AUTHORIZATION OF PARTICIPATION: I give all members of my family permission to participate in any program (s), camps 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, its officers, employees, teachers, and coaches from 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 treatment at the nearest Medical Facility in case of emergency.
ENROLLMENT AGREEMENT AND REFUND POLICIES: This will secure a place for your child(ren) in a limited class for the full season. Payments accepted by Cash, Check, Master Card, Visa, or Discover. Your tuition, minus a $10 processing fee, will be refunded with written notice of withdrawal given at least 48 hours prior to the beginning of your first scheduled session/class. 50% of your tuition , minus a $10 processing fee, will be refunded with written notice of withdrawal given prior to the 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 $15, will be charged for any returned check. 10.0 Academy reserves the right to cancel any classes due to weather or 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 acknowledgment of risk and waiver of liability, having been read thoroughly and understood completely, signed voluntarily as to its content and intent. I hereby execute and deliver this waiver and release form, to permit my child's / children's participation in the program (s). I have read and agree to the enrollment conditions, as stated above.
Parent / Guardian Signature: ______________________________ Date ____/_____/_____