Student Registration Form-Auto-Pay Credit Card Form printable pdf download

STUDENT REGISTRATION FORM

3949 W. Costco Dr., #101, Tucson, AZ 85741

520-742-1444

Parent/Guardian/Billing Contact:

Parent/Guardian Name:______________________________________________________________________________________________________

Address:________________________________________City:________________________State:__________Zip:____________________________

Mom’s Cell Phone#:_________________Dad’s Cell Phone#______________________Work Phone#_______________________________________

E-Mail:__________________________________How did you Hear about us?__________________________________________________________

Emergency Contact Name:_________________________________________Phone #____________________________________________________

Student Information:

Student Name:______________________________________________________________________Birthday:_____________________________

Special Medical Conditions/Allergies/Restrictions:________________________________________________________________________________

Assumption of Risk, Waiver of Liability:In consideration of participating in the Arizona Dynamics Gymnastics & Cheer I represent that I understand the nature of this activity and that I am

qualified, in good health and in proper physical condition to participate in such activity. I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue

participation I the activity. I fully understand that this activity involved risks of bodily injury, including permanent disability, paralysis and death, which may be caused by my own actions, or

inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the “releases” named below; and that there may be other risks either

not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, cost, and damages I incur as a result of my participation in

the activity. I hereby release, discharge, and covenant not to sue Arizona Dynamics, its respective administrators, directors, agents, officers, volunteers, and employees, other participants

any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the activity takes place, (each considered one of the “REALEASEES” herein) from all liability, claims,

demands, losses, or damages, on my account caused or alleged to be caused in whole or in part by the negligence of the “releases” or otherwise, including negligent rescue operations and

future agree that if, despite this release, waiver of liability, and assumption of risk, I or anyone on my behalf, makes a claim against any Releasees, I will indemnify, save, and hold harmless

each of the Releasees from any loss, liability, damage or cost, which any may incur as the result of such claim.

I have read the Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement, understand that I have given up substantial rights by signing it and have signed freely and

without inducement.

Media Waiver: I also understand and give permission for photographs and videos of names persons and/or participants and/or myself be used in print or broadcast media as deemed

appropriate for the promotion of Arizona Dynamics Gymnastics & Cheer Center.

_____________________________________________________

________________________________________________

Parent or Guardian Signature

Date

Printed Student Name

Payment/Billing Information:

______I would like auto billing. I agree that my credit/checking account will be charged two weeks prior to each session start date for my balance due or on the

first day of the month for monthly tuition. Auto billing only applies to reoccurring session tuition. Fees for other products/services shall be paid for at the time of

purchase and/or registration. I understand if the above named persons and/or participants are enrolled in a program that has reoccurring tuition I am

continuously enrolled in the program. I will incur reoccurring monthly/session tuition charges on my account until I submit a Arizona Dynamics drop request.

This request must be made 30 days prior to withdraw date.

______I will pay my account balance before the 1

day of each session at Arizona Dynamics. If my payment is not received before the due date I understand that

I will be dropped from the class roster and re-enroll fee of $10 will be charged. I understand I am continuously enrolled until I submit a drop request to Arizona

Dynamics which is due ten days prior to the session start date.

______REFUNDS or CREDIT for missed classes or withdraw prior to conclusion of session is not allowed for any reason. I have read and completely understand

and agree to all terms and conditions of this agreement.

Signature:______________________________________________________________________________________Date______________________________________