GYMNASTICS CAMP REGISTRATION FORM

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POMEROY GYMNASTICS, INC.

SUMMER CAMP 2020 REGISTRATION FORM

Student’s Name__________ Gender ______Age ____ Date of Birth ______/_____/_____

Street Address _____________________ City _____________ State _____Zip_______

Mother’s Name _______________ _____ Father’s Name _________________________

Home Phone #____-_____-____Work Phone #___-____-____ Cell Phone #___-____-___

Emergency Contact and Phone Number _____________________________________________ _______-_______-_______

Are there any medical conditions to which we should be alerted? _____________________________________________________________________

_____________________________________________________________________

CAMP INFORMATION

WK DATES AM CARE PM CARE BOTH ½ DAY FULL DAY

1 CLOSED $00.00 $00.00 $00.00 $000.00 $000.00

2 CLOSED $00.00 $00.00 $00.00 $000.00 $000.00

3 CLOSED $00.00 $00.00 $00.00 $000.00 $000.00

4 July 6-July 10 $60.00 $110.00 $150.00 $220.00 $300.00

5 July 13-July 17 $60.00 $110.00 $150.00 $220.00 $300.00

6 July 20-July 24 $60.00 $110.00 $150.00 $220.00 $300.00

7 CLOSED $00.00 $00.00 $00.00 $000.00 $000.00

8 Aug. 3-Aug. 7 $60.00 $110.00 $150.00 $220.00 $300.00

9 Aug. 10-Aug. 14 $60.00 $110.00 $150.00 $220.00 $300.00

10 Aug. 17-Aug. 21 $60.00 $110.00 $150.00 $220.00 $300.00

# OF WKS x TUITION __ ___ x __________ # OF WKS AM CARE ______ x __________

5% DISCOUNT -__________ # OF WKS PM CARE ______ x __________

SUB TOTAL __________ # OF WKS BOTH ______ x __________

TOTAL $ _______________

Deposit of 50% of tuition is due at registration. No refunds or credits will be given after June 1, 2020. Balance of tuition is due on the Monday of the scheduled week.

ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY

As legal guardian of ______________ , I hereby consent to aforementioned person participating in Pomeroy Gymnastics, Inc.’s programs. I recognize the potential for injuries, which may occur in any activity involving height or motion. I understand that it is the express interest of Pomeroy Gymnastics, Inc., to provide for the safety and protection of my child and, inconsideration for allowing my child to use these facilities; I hereby forever release Pomeroy Gymnastics, Inc., and employees. As legal guardian of the aforementioned person, I hereby agree to individually provide for the possible future medical expenses that may be incurred by my child as a result of any injury sustained while training at or performing for Pomeroy Gymnastics, Inc. This acknowledgment of risk and waiver of liability, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.

_____________________________ _________________________________________________________________________________________________________________________

Parent or Legal Guardian’s Signature Date

SUMMER CAMP 2020.pdf

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Jeff Pomeroy,

Feb 3, 2020, 7:55 AM

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