TRC REGISTRATION SOUTH - TRC Gymnastics

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LAST NAME: *

DATE OF BIRTH: *

FIRST NAME: *

GENDER: *

CLASS ID: *

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TRIAL DATE: *

START DATE:

TOTAL DUE:

MAILING ADDRESS: *

Address Line 1

Address Line 2

City

State

Zip Code

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MOTHER: *

First

Last

MOM EMAIL: *

MOM PHONE:

FATHER: *

First

Last

DAD EMAIL: *

DAD PHONE:

EMERGENCY CONTACT: *

AUTHORIZATION FOR EMERGENCY CARE

IN THE EVENT THAT I, OR (BELOW) CANNOT BE REACHED, IN THE EVENT OF A MEDICAL EMERGENCY; I AUTHORIZE EMERGENCY MEDICAL PROFESSIONALS AND, OR A TRC GYMNASTICS EMPLOYEE TO TRANSPORT (CHILDS NAME - BELOW) TO THE NEAREST EMERGENCY MEDICAL FACILITY WHERE HE OR SHE CAN BE TREATED BY A MEDICAL DOCTOR OR DENTIST.

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GUARDIAN/PARENT *

CHILDS NAME *

First

Last

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INSURANCE COMPANY: *

POLICY OR GROUP NUMBER: *

SUBSCRIBER: *

PHONE:

MY CHILD HAS THE FOLLOWING SIGNIFICANT HEALTH HISTORY / CONDITION / ALLERGIES:

AUTHORIZATION FOR AUTO PAYMENTS

I represent and warrant that if I am purchasing something or paying for a service from this facility or from other merchants through this facility that (I) any credit card or bank account draft (SCH Draft) information that I supply is true and complete, (II) charges incurred by me will be honored by my credit card company or financial institution, and (III) I will pay the charges incurred by me at the posted prices, including any applicable taxes, fees, and penalties.

I hereby authorize (if online payment is made or autopay information is provided) this facility to charge my ACH draft, or credit card account. I understand that a 30-day written notice is required to terminate billing and I am responsible for payment whether or not my student attends classes until I notify TRC Gymnastics Inc. by submitting a TRC Drop Notice Form to drop my child from class/ classes.

Should I dispute a charge through my financial institution this will constitute a breach of contract possibly resulting in , but not limited to, penalties, additional fees, collection, legal action, and/ or termination of any and/ or all current and future services.

THIS POLICY IS SUBJECT TO CHANGE WITHOUT NOTICE

TYPE NAME AS SIGNATURE *

DATED: