EmailMe Form - KIDS DAY OUT Online Form

Kids Day Out *

Child's Name 1 *

First Last

Birth Date *

MM / DD / YYYY

Age of your child.

Any Allergies *

Enter NONE or list any allergies or special information

Child's Name 2

First Last

Birth Date

MM / DD / YYYY

Age of your child.

Any Allergies

Enter NONE or list any allergies or special information

Child's Name 3

First Last

Birth Date

MM / DD / YYYY

Age of your child.

Any Allergies

Enter NONE or list any allergies or special information

Child's Name 4

First Last

Birth Date

MM / DD / YYYY

Age of your child.

Any Allergies

Enter NONE or list any allergies or special information

Home Phone *

### - ### - ####

Home Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Health Ins. *

Health Insurance Carrier

Parent's Name *

First Last

Mother's Name or Main Guardian's Name

Parent's Cell # *

### - ### - ####

Mother's Cell Phone or Main Guardian's Cell Phone

Family Email *

Mother's e-mail or Main Guardian's e-mail

Parent #2

First Last

Father's Name or Secondary Guardian's Name

Parent #2 Cell

### - ### - ####

Father's Cell Phone or Secondary Guardian's Cell Phone

Emergency Name *

First Last

Emergency Contact other than Parent or Guardian.

Emergency # *

### - ### - ####

Emergency Phone Number other than Parent or Guardian

KIDS DAY OUT DATES & TIMES:

Specific program information, dates and times are located on our website at
www.worldcupgymnastics.com.

PRICING:

$35 for the 1st child; $32 for each sibling

PAYMENT INFORMATION:

Payment Method *

Credit Card/DBT

Credit Card

AMEX

Discover

Master Card

VISA

Choose the Credit Card you wish to use.

Card Number

Make sure your Credit Card number is correct.

Exp. Date

MM / DD / YYYY

Enter 2 digits for the month and day; 4 digits for the year.

Special Notes

Let us know of any special information or request.

RULES/POLICIES, WAIVER/RELEASE & ACKOWLEDGEMENT:

Read below and check marked boxes to confirm.

Rules/Policies *

I understand the Rules/Policies information.

PAYMENT: No registration will be valid without payment.

CLOSURES: In the event of inclement weather or for some other emergency, the gym may have to be closed. Call (914) 238-4967 or visit our website at worldcupgymnastics.com for closure details and updates.

REFUNDS/CREDITS: No refunds will be given unless notified by the Friday before the scheduled Kids Night Out. Exceptions are only allowed with a doctor's note.

WHILE AT WORLD CUP GYMNASTICS: Parents and non-participating siblings are not allowed on the gym floor. Spectators may observe the event from the halway or the balcony. Do not call out or distract your child during the event. Children under the age of 12 who are not participating in Kids Night Out may not be left unattended on the premises, and children must be supervised at all times. Have your children obey the Gym Rules and Policies at all times. World Cup is not responsible for any lost or stolen items. Valuable items may be left with the front desk.

Waiver/Release *

I consent to the Waiver/Release information.

WAIVER: World Cup and its staff recognize our obligation to make our clients aware of the risks and hazards associated with the sport of gymnastics, tumbling, trampoline, cheerleading, Romperee, etc. World Cup Gymnastics and its staff will not accept responsibility for injuries sustained by any child, parent and/or caregiver during the course of any gymnastics activities and/or while arriving or departing or waiting anywhere on World Cup Gymnastics premises. Parents and/or caregivers should be aware of, and educate their children about the possibility of injury. Parents and/or caregivers should also encourage their children to follow all safety guidelines and World Cup staff instructions. Gymnastics can be dangerous and lead to injury. Students, parents and/or caregivers may suffer injuries, possibly minor, serious or catastrophic in nature.

Therefore, being fully aware of the risks and possibility of injury involved, I consent to have my child and/or myself participate in the programs offered by World Cup Gymnastics. I waive and release all rights and claims for damages that I or my child may have against World Cup Gymnastics and/or its representatives and staff, whether paid or volunteer. With this in mind, in the event of an injury or illness to my child or myself, and with the knowledge that World Cup staff members are not physicians or medical practitioners of any kind, I consent to the administration of temporary first aid to me and/or my child by World Cup staff if they deem necessary, contacting a doctor and/or seeking medical help, transportation by a World Cup staff member and/or its representatives, whether paid or volunteer, to any health care facility or hospital, calling 911 and/or an ambulance, etc. I also affirm that I now have and will continue to provide proper hospitalization, health and accident insurance coverage which I consider adequate for both my child's and/or my own protection. I also understand that it is my responsibility to continually remind my child about the dangers of gymnastics, tumbling, trampoline, cheerleading, Romperee, etc. injury. World Cup Gymnastics staff members will continually remind the children, parents and/or caregivers of safety guidelines during our programs, as well as post signs throughout the premises.

PHOTO RELEASE: I authorize that World Cup Enterprises LLC has the right to use all photographs or videos taken of my child or children during Kids Night Out, Special Days, camp, classes, practices, field trips, etc. for advertising or promotional materials, or on its website.

Acknowledgement *

I accept World Cup's terms and conditions.

I accept World Cup's Rules/Policies, Waiver/Release & allow my payment to be processed by World Cup administration.

Registration Date *

MM / DD / YYYY

Enter the date you submit this registration Form.

Review all information and make any necessary changes.

Make sure all information is correct before processing registration form.