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FLYING GAONAS GYM: PARTICIPANT REGISTRATION
Participant's
Name:________________________
Age:_______ Date of Birth:___________
Parent or Legal Guardian's Name (for minors)___________________________________________
Street
Address:____________________________
City:________________ State:______ Zip:_________
E-mail address:______________
Home
Phone: (___)_________
Work Phone: (___)_________
Cell Phone: (___)_________
Emergency contact:______________________________
Phone:
(___)____________ Relationship:____________________
Physician:______________________
Phone: (___)_________
Paragraph
3) of the Release, Assumption of Risk and Covenant Not to Sue Agreement states, "...it is important that I accurately and
completely inform them of my level of expertise and any disabilities or special conditions which I have which may impair or
interfere wth my ability to participate safely in flying trapeze or other circus arts. I further agree to provide any such
information relative to my abilities or impairments, and to assume full responsibility for any failure on my part to do so
properly."
Please provide all such information here. Use reverse if necessary.
________________________________________________________
________________________________________________________
________________________________________________________
Signature
of participant/minor participant's parent or legal guardian Date
By signing below, I give
permission to the Flying Gaonas Gym to take photographs or videos of me during class and to use these as needed for publicity
purposes. This may or not include publishing these on the internet.
_______________________________________________________
Signature
of participant/minor participant's parent or guardian Date
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