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Student Information
 
Class Day Time Level Coach
Student Name :
Emergency Contact Name :
Phone (Different frome below) :
Date of Birth :
Age
Email :
List any Physical Limitations or Medications :
   
Parent Information
Name
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Address
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City
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State
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Zip Code
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Home Phone
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Work Phone
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Cell Phone
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Email
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Employer
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Occupation
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Spouce/Guardian Name
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Address
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City
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Home Phone
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Work Phone
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Cell Phone
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Friend Name :

Release consent for video or photographs

As parent or guardian, I release AGYM, Inc. to use the video or photographs taken of my child/children listed below.  The media taken at the AGYM facility is to be used for identification and promotional purposes.

Childs Name Childs Name
Parent Guardian
Release of liability and consent agreement :

The undersigned student and/or parent or legal guardian of student of AGYM, Inc., by signing this contract acknowledges that this contract contains release and other risk-shifting provisions which may operate to shift risk from AGYM, Inc., to the student of AGYM, Inc.  The student of AGYM, Inc. expressly accepts any and all responsibilities and duties resulting from such provisions.  The individual(s) signing this agreement admit(s) reading and understanding the terms contained in this agreement  In case of injury or illness I (we) give consent and allow the staff of AGYM, Inc., the authority to obtain medical assistance and treatment, as they may deem necessary.  I understand that neither AGYM, Inc., it’s employees nor servants shall be responsible for any medical expenses so incurred. I (we) have read, understand, and agree to the above statements.  By the execution hereof I (we) do further bind myself, my child, or legal ward, and all heirs, executors, administrators, successors or assigns of same.
Executed this ______ day of _____________, 2004

Signature of Parents  
       I Agree the Terms and Conditions
Copyright © agym, 2005 All Rights Reserved.