GYMJAM Application

CAMPER INFORMATION

________________________________________________________________________________________________
Camper Last Name-------------First----------Middle-----------Birthdate---------Sex (M/F)

________________________________________________________________________________________________
Home Address---------------------------City------------------State-----------------Zip

________________________________________________________________________________________________
Parent's/Guardian's Names-----------------------------Phone----------------------Alternate Phone

_______________________________________________________________________
Email------------------------------------------------------------------Club Name

_______________________________________________________________________
1st Choice-----------------------------------------2nd Choice-------------------------------- 3rd Choice
Roommate Requests (Please limit to 3.)

_______________________________________________________________________
List any Medical Needs, Allergies, Medications, etc.

Current Gymnastics Level:__________________  Level competed this year, if applicable:  ______________________ 

Highest All-Around this year:  _________ Minimum of Pre-team or Level 3 required

Medical Insurance is required for all Campers.

_______________________________________________________________________
Insurance Company----------------Policy #--------Group #----------------Phone

_______________________________________________________________________
How did you hear about GymJam?
(USAG Magazine, Internet, From my club, Word of mouth, Other)

Put an X indicating what type of camper you would like to be:
____ Resident $699
____ Day Camper $555 (9am-5.30pm)

Session Fee ($699 Resident/$555 Day Camper): _________________
*Early Enrollment Discount ($60 if paid in full by March 15, 2008): _________________
Please pay balance by May 1, 2008
Team Discount ($20 for team of 5-9, $30 for teams of 10+): _________________
Sibling Discount ($30 for each child): _________________
Total Session Fee Due: _________________
Amount Enclosed: _________________
*No other discounts apply. --------------------------

Please enclose Total Session Fee or a $150 Deposit. Total Session Fees minus $150 Deposit = Balance Due. Balance Due May 1, 2008. Make checks payable to GymJam. Mail to: GymJam, 26515 Ruether Ave., Santa Clarita, CA, 91350.

ph:661-251-3390 f:661-251-9968

RELEASE AND CONSENT AGREEMENT

The undersigned student and/parent or legal guardian of the student (hereinafter referred to collectively and individually as "the Student") of GYMJAM, by signing this Agreement, expressly acknowledges that this Agreement contains a release which may operate to shift risk and liability from GYMJAM to the Student. The Student expressly accepts the responsibilities and duties resulting from such provisions. The Student further acknowledges that some of the activities regularly conducted at GYMJAM involve, as do any gymnastics activity, a risk of injury including but not limited to injury resulting in paralysis or even death. The individual(s) signing this Agreement have read, understand and expressly agree to the terms contained in this Agreement.

I/we, the undersigned Student and/or parent or legal guardian of the Student of GYMJAM, for and in consideration of enrollment in GYMJAM, hereby voluntarily and knowingly execute this release with the express intention of releasing GYMJAM, its officers, agents, employees or servants from any and all claims, actions, demands or rights to monetary judgment whatsoever arising from any and all injury or physical harm which may occur to the Student, including specifically those that may arise out of, or be occasioned by, directly or indirectly, any negligent act(s) or omission(s) of GYMJAM during the Studentís attendance at and participation in any activities associated with GYMJAM both on and off the GYMJAM premises. In addition to any gymnastics related activity, this release is intended to and does extend to any injury or damage resulting from transportation between housing, gym, recreation and other activities provided by GYMJAM.

MEDICAL CONSENT

I, the Student and undersigned parent or legal guardian of the Student do hereby expressly grant to the staff of GYMJAM in the case of emergency, the authority to obtain medical assistance and treatment as they deem necessary. I give my express permission and consent for a licensed doctor or physician to administer the necessary aid to the Student should he/she become injured or sick while in attendance at or while participating in any activity associated with GYMJAM and to do so without having to wait until a parent, a legal guardian or other relative is contacted. I fully release GYMJAM and its officers, directors, agents, employees and servants from any claims, actions, demands or damages resulting from the decision to seek or the administration of medical assistance and I understand that neither GYMJAM, its officers, agents, employees nor servants shall be responsible for any medical expenses incurred on behalf of the Student, and that I am responsible for all payment of medical expenses so incurred.
I have read, understand, and expressly agree to the above statements. By the execution hereof I do further bind myself, my child or legal ward and all heirs, executors, administrators, successors or assigns of the same.

Executed this __________________ day of _______________________, 2008

__________________________________________________________________________
Signature of Student OR Signature of Parent/Legal Guardian (if student is under 18 years of age)

__________________________________________________________________________
Print Name