FLIP-N-FUN GYMNASTICS @
LAFAYETTE THEATRE ACADEMY - 83 Lafayette Circle (next to French Bakery)
REGISTRATION AND INSURANCE FORM
FIRST CHILD_____________________________________________________ AGE_________ DOB____________
CLASS ATTENDING: DAY___________ TIME_________ SESSION_________
SECOND CHILD___________________________________________________ AGE_________ DOB____________
CLASS ATTENDING: DAY__________ TIME__________ SESSION__________
PARENT/GUARDIAN(S) NAME (first & last) HOME CELL
PARENT/GUARDIAN: ______________________ __________________ PH# ______-________ _______-________
PARENT/GUARDIAN: ______________________ __________________ PH# _______-_______ _______-________
ADDRESS:
STREET____________________________________________ CITY____________________ ZIP____________
EMAIL CONTACT: __________________________________________________________
Flip-n-Fun Gymnastics (Ms. Diane) is here to provide a professional service to your child. If your child has any special needs or learning differences that could be better served through a particular teaching approach, please communicate this to be me. This information is for the owner and is completely confidential.
____________________________________________________________________________________________________
INSURANCE CARRIER: _____________________________POLICY#_____________________________
MEDICAL / EMERGENCY INFORMATION:
IN CASE OF AN ACCIDENT OR EMERGENCY OUR POLICY IS TO ADMINISTER FIRST AID AND IF NEEDED CALL “911” AND YOU, THE PARENT/GUARDIAN.
Does your child have any allergies? YES_______ NO_______
Please explain if answered YES to question regarding Allergies and how or if they may flare up during class and how best to help your child___________________________________________________________________
_________________________________________________________________________________________
PERSON TO NOTIFY IN CASE OF AN EMERGENCY IF PARENT IS NOT AVAILABLE:
NAME ____________________________________________________________ TELEPHONE______ __________
Please note that all above information provided is for the use of Flip-N-Fun Gymnastics only and will not be distributed to anyone.
Check payable to: Flip-N-Fun Gymnastics
Mail to: Flip-N-Fun Gymnastics - 841 Ava Court, Lafayette, CA, 94549