CAMPER INFORMATION
________________________________________________________________________________________________
Camper Last Name---------------------------First-------------------Middle-----------------Birthdate-------------Sex
(M/F)
________________________________________________________________________________________________
Home Address--------------------------------City-------------------------------State--------------------------------Zip
________________________________________________________________________________________________
Parent's/Guardian's Names---------------------------------------Home Phone------------------------------Cell
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, Inside Gymnastics Magazine, Internet, From my club, From a meet, Word of mouth, Other-explain)
Put an X indicating what type of camper you would like
to be:
____ Resident Session 1 $575 (Check in 9am-10am Sat. June 20th, Check out 5:30pm Tues, June 23rd)
____ Day Camper Session 1 $385 (9am-5:30pm, June 20-23)
____ Resident Session 2 $575 (Check in 9am-10am Wed. June 24th, Check out 5:30pm Sat., June 27th)
____ Day Camper Session 2 $385 (9am-5:30pm, June 24-27)
Session 1 Fee ($575 Resident/ $385 Day Camper): ___________
Session 2 Fee ($575 Resident/ $385 Day Camper): ___________
Pay in full by March 1st, deduct $75 per session: ______(____)
Pay in full by April 1st, deduct $50 per session: ______(____)
Deduct $100 if enrolling in both sessions: ______(____)
Team Discount ($20 for team of 5-9, $30 for teams of 10+): ______(____)
Sibling Discount ($25 for each child): ______(____)
Total Session Fee Due: ___________
Amount Enclosed or to be Charged ($150 deposit or full amount): ______(____)
Amount Due By May 15th, 2009: ___________
To pay with Visa or MC (no Amex or Discover): Credit Card #: ____________________________ Exp. ____________
Billing Address if different from above: ________________________________________________________________
Billing Address Zip Code: _____________________________ Three Digit Security Code (back of card) ____________
Please enclose Total Session Fee or a $150 Deposit. Total Session Fees minus $150 Deposit = Balance Due.
Balance Due May 15, 2009. Make checks payable to GymJam, 26515 Ruether Ave., Santa Clarita, CA, 91350.
Fax 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.
PHOTO RELEASE
GYMJAM periodically takes photographs and/or video for advertising purposes including but not limited to print ads and website.
I hereby grant GYMJAM permission to use my likeness (or my minor child) in a photograph in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of GYMJAM and will not be returned. I hereby irrevocably authorize GYMJAM to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing GYMJAM’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my (or my minor child’s) likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless and release and forever discharge GYMJAM from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I am 21 years of age and am competent to contract in my own name and on behalf of my minor child. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
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 _______________________, 2009
Parent's Signature ________________________________Print Parent's Name__________________________________
Child's Signature ________________________________Print Child's Name___________________________________
