BIRTHDAY PARTY SIGN-IN

Whose birthday party are you attending? *

Date of birthday party? *

Is a member of your family currently enrolled in classes at PIM? *

Parent/ Guardian Info

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Emergency Contact Info *

Child Information

Child #1

Child's Name *

Child's Birthdate *

Child #2

Child's Name (2)

Child's Birthdate (2)

Child #3

Child's Name (3)

Child's Birthdate (3)

Waiver

ASSUMPTION OF RISK *

As the parent/legal guardian of the above-mentioned person(s), I am fully aware of the potential dangers, including the risk of catastrophic injury, paralysis, and even death, as well as other damages and losses associated with participation in a sport or activity involving height or motion. I am fully aware that height and motion are inherent to the programs offered by Power in Motion, and I hereby give my consent for my child(ren) or the person I am guardian for, to participate.

RELEASE OF LIABILITY *

I, as the parent or guardian of the above-mentioned person(s), agree and acknowledge that I have made a voluntary choice to allow my child(ren) or person I am guardian for, to participate in these activities at Power in Motion with the risk that such activities present. In consideration of being permitted to participate in a gymnastics or fitness instructional program, event or competition, at Power in Motion, I agree to assume any and all risk of injury or death which might be associated with, or result from the participation in such activities by my child(ren)'s or the person I am appointed guardian for. I agree to accept all responsibility for the risks, conditions and hazards which may occur whether now known or unknown, on behalf of myself and/or my child(ren) or for the person I am appointed guardian for.

PERMISSION TO TREAT *

I fully understand that PIMG&FC staff members are not physicians or medical practitioners of any kind. With the above in mind, I hereby provide my express consent that PIMG&FC staff may call our doctor and in addition, may seek medical help, including transportation, such as the calling of an ambulance for my child(ren) or the person I am guardian for. I agree to provide for all medical expenses incurred by me as a result of injury sustained by my child(ren) or the person I am guardian for, while participating at PIMG&FC.

PHOTO/ VIDEO RELEASE

I grant permission to Power in Motion to use photographs or videos of my child(ren) or the person I am guardian for, for promotion of Power in Motion.

PARENT/GUARDIAN SIGNATURE *

I have fully read and understand the above ASSUMPTION OF RISK, RELEASE OF LIABILITY, PERMISSION TO TREAT, PHOTO/ VIDEO RELEASE and all of its terms. I have signed this agreement freely and voluntarily agree that it is binding upon me, my child(ren) or the person I am guardian for, including my heirs, assigns and legal representatives. In addition, I confirm that I am the parent/legal guardian of this registrant(s). Typed name below represents parent/ guardian signature.

Signature *

Clear