Participant Information

First Name: Middle Initial: Last Name:

Age:    Date of Birth:

Address:

City: State: ZIP:

Home Phone: Cell Phone:
Email Address:

Mother's Name: Mother's Work Phone:
Father's Name: Father's Work Phone:

Has the info above changed in the last year?  Yes No
I give permission for my gymnast's photo to appear on the website or Facebook page.  Yes No

How did you hear about Andy Valley Gymnastics?


Choose Class(es)

A non-refundable $30 deposit is required to hold your space. There is an additional $30 annual insurance fee for each participant (or $50 per family), due at registration, for the time period 8/29/2016-8/29/2017. If you are registering mid-session, please pay the $30 deposit, and contact us to determine your prorated fee.

SESSION I:
8/28/2017 – 11/4/2017
SESSION II:
11/6/2017 – 1/20/2018
SESSION III:
1/22/2018 – 4/7/2018
SESSION IV:
4/9/2018 – 6/24/2018
SUMMER:
6/25/2018 – 8/26/2018
Gym Toddler Gym Toddler Gym Toddler Gym Toddler Gym Toddler
Mommy & Me Mommy & Me Mommy & Me Mommy & Me Mommy & Me
Kinder Gym Kinder Gym Kinder Gym Kinder Gym Kinder Gym
Advanced Kinder Gym Advanced Kinder Gym Advanced Kinder Gym Advanced Kinder Gym Advanced Kinder Gym
Girls Rec Age 5-6 Girls Rec Age 5-6 Girls Rec Age 5-6 Girls Rec Age 5-6 Girls Rec Age 5-6
Girls Rec Age 7+ Girls Rec Age 7+ Girls Rec Age 7+ Girls Rec Age 7+ Girls Rec Age 7+
Boys Rec Boys Rec Boys Rec Boys Rec Boys Rec
Girls Advanced Rec Girls Advanced Rec Girls Advanced Rec Girls Advanced Rec Girls Advanced Rec
Cheer Tumbling: Beginner Cheer Tumbling: Beginner Cheer Tumbling: Beginner Cheer Tumbling: Beginner Cheer Tumbling: Beginner
Cheer Tumbling: Intermediate Cheer Tumbling: Intermediate Cheer Tumbling: Intermediate Cheer Tumbling: Intermediate Cheer Tumbling: Intermediate
Cheer Tumbling: Excel Cheer Tumbling: Excel Cheer Tumbling: Excel Cheer Tumbling: Excel Cheer Tumbling: Excel
Cheer Tumbling: Advanced Cheer Tumbling: Advanced Cheer Tumbling: Advanced Cheer Tumbling: Advanced Cheer Tumbling: Advanced
Cheer Tumbling: Standing Cheer Tumbling: Standing Cheer Tumbling: Standing Cheer Tumbling: Standing Cheer Tumbling: Standing
Competitive Team: Boys
Competitive Team: Girls

Participant Medical Information

  1. Does the participant have any existing medical problems?  None Asthma Diabetes Seizures Heart Problems Musculoskeletal Problems (ex: back, neck, bone, or joint problems, scoliosis) Other (please explain)
  2. Does the participant have to use medications on a regular basis?  yes no If yes, what medication and use?
  3. Does the participant wear any appliances/devices?  None Eyeglasses/contacts Hearing Aids Dental Appliances Splints/Orthotics Other (please explain)
  4. Does the participant have any medical conditions that might interfere with his/her participation in the sport of gymnastics? If yes, what condition?
  5. Does the participant have any known allergies? If yes, please specify:

Emergency contact name: Emergency contact phone:
Doctor’s Name: Phone:
Insurance Company: Phone: Hospital Preference:

Emergency Medical Care Authorization: In the event that the Participant should become accidentally injured or ill while at Andy Valley Gymnastics (AVG) or any related activity in which the participant may be involved, we hereby authorize AVG or AVG agents to arrange for whatever emergency medical care is deemed necessary and reasonable at the time, including transport to a local hospital Emergency Dept. and agree to be solely responsible for all expenses and costs related to such emergency treatment and agree to indemnify and hold harmless AVG, its shareholders, directors, officers, employees, coaches, agents and Parent Association for any expenses and costs it may incur related to such treatment.

Consent & Release: We hereby consent that the Participant above may be involved in gymnastics and any related activities provided by AVG. We unconditionally release, hold harmless, waive, discharge and covenant not to sue Andy Valley Gymnastics, its shareholders, directors, officers, employees, coaches, agents and Parent Association from any & all liability for damages and costs and any claim or demand therefore, directly or indirectly arising out of or related to any injuries that the above named Participant might sustain while engaged in the practice or performance of any gymnastic activity while at Andy Valley Gymnastics or at any event in which the Participant, Andy Valley Gymnastics, employees, coaches, agents or Parent Association are involved.