For Internal Use Only:

GCG#__________________
Class___________________
Session/Start Date:________
Fee:____________________
Card on File _____________
In Contacts ______________
Account Name________________
Payment/session____ monthly_____

KIPPERS SCHOOL OF GYMNASTICS

2014-2015 REGISTRATION FORM
Returning Member___ New Member____ Has your child participated in gymnastics before? ______
How did you learn of Kippers? Newspaper____ School Newsletter___ Word of Mouth___ Other_______

Name __________________________________________________ Male _____ Female ____

Birth date: Month________________________ Day______ Year______________ Age_______
Address (street and mailing):
______________________________________________________
Parents / Guardians Name (s): ___________________________________________________
Home Phone ______________ Mothers Cell_______________ Fathers Cell ______________
Mothers Work Phone ________________ Fathers Work Phone ________________________
Alternate Name and Phone (babysitting, emergency, cancellations) ______________________
Relation to alternate________________________
Is there a parent / custodial arrangement that staff should be aware of? ___________________
____________________________________________________________________________

MEDICAL INFORMATION
Please provide additional details on any medic alert situations (severe allergy, asthma,
disabilityetc):________________________________________________________________
____________________________________________________________________________
Epi-Pen? ____________________ Other? _________________________________________
Health Card Number ______________________________ Expiry _______________________
Family Doctor ____________________________________ Phone ______________________
Mothers Occupation_______________________ Fathers Occupation ___________________
Email Address:_______________________________________________________________

MEDIA RELEASE
Kippers will sometimes take pictures / video during classes for promotional and educational purposes.
Kippers has a weekly newspaper column which may feature different classes at any given time.
I, ____________________________, give permission for Kippers to use pictures / footage and the name
of my child (please print) _______________________________________________ for promotional use.
Signed: ________________________________________ Date: _______________________________
Waiver / Parent Signature
It must be understood that there is an inherent risk in any active program and we, Kippers School of
Gymnastics, staff, Executive and Coaches are in no way responsible for damage to or loss of property; or
injury to participants, unless proven negligent. We, therefore, ask you to release, absolve, indemnify and
hold harmless the Kippers School of Gymnastics, staff, Executive, Coaches, organizers and sponsors in
the case of injury to your child.
Parent / Guardian Signature: ____________________________________________________________
Date: ____________________________
All information provided to our organization is kept in strict confidence

PRIVACY POLICY TAGLINE FOR USE ON CLUB REGISTRATION FORMS

Personal Information
Protection and Electronic Documents Act (PIPEDA
I am aware that Kippers School of Gymnastics gives specific personal information to Gymnastics Nova
Scotia (GNS) for registration purposes only. GNS may then provide specific information to Gymnastics
Canada for registration or competition purposes only.
Kippers School of Gymnastics does not sell or divulge personal information to any other source other
than that required for a medical emergency with parent or guardians consent.
Signature (Member or parent/guardian if member is under 18 years of age: _______________________
Date: ________________________
FIRST AID CONSENT
I (please print), _______________________________________, Mother / Father Guardian (circle one),
give my permission to the staff of Kippers School of Gymnastics to administer first aid to my
son / daughter (circle one), Name (please print)_________________________________________, in the
event of an emergency.
I also consent to have a physician and / or emergency medical service provide treatment as required; in
the judgment of the attending physician.
Signature of Mother: _____________________________________________________Date: _________
Signature of Father: _____________________________________________________Date: _________