FLYING GAONAS GYM: PARTICIPANT REGISTRATION
Participant's Name:________________________
Age:_______ Date of Birth:___________
Parent or Legal Guardian's Name (for minors)___________________________________________
Street Address:____________________________
City:________________ State:______ Zip:_________
E-mail address:______________
Home Phone: (___)_________
Work Phone: (___)_________
Cell Phone: (___)_________
Emergency contact:______________________________
Phone: (___)____________ Relationship:____________________
Physician:______________________
Phone: (___)_________
Paragraph 3) of the Release, Assumption of Risk and Covenant Not to Sue Agreement states, "...it is important that I accurately and completely inform them of my level of expertise and any disabilities or special conditions which I have which may impair or interfere wth my ability to participate safely in flying trapeze or other circus arts. I further agree to provide any such information relative to my abilities or impairments, and to assume full responsibility for any failure on my part to do so properly."
Please provide all such information here. Use reverse if necessary.
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Signature of participant/minor participant's parent or legal guardian Date
By signing below, I give permission to the Flying Gaonas Gym to take photographs or videos of me during class and to use these as needed for publicity purposes. This may or not include publishing these on the internet.
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Signature of participant/minor participant's parent or guardian Date
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