AGC Special Questionaire

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SPECIAL NEEDS STUDENT SCHOLARSHIP APPLICATION 2008

Student Information

Name: ________________________________Age:_______

Home phone :(___) ___________________Birth Date: ______________

Address: ______________________________City: ________________ State: ____Zip: _____________

School: ___________________Grade: ______

Parent’s e-mail: ______________________________________

We have a variety of ways for your child to participate in our program. Please let us know what your interests are.

PROGRAM INTREST

Age appropriate group class __

½ hour one-on-one __

Free play ___

Class days that work for you: __________________

Class times that work for you: _____________________

Parents’ Information

Mother’s name ____________________Work#______________Cell#___________

Father’s name

______________________Work # _______________Cell#___________

Please tell us about your child’s special needs:

________________________________________________

Please tell us anything medically that we need to be aware of:

________________________________________________

Any physical limitations that we need to be aware of?

________________________________________________

Are there any physical activities your child should not participate in?

________________________________________________

What physical activities is your child currently participating in?

________________________________________________

Is your child aggressive? yes/no

What are the common triggers?

________________________________________________

Why do you feel gymnastics might benefit your child?

________________________________________________

Is there any other information you would like us to know about your child?

________________________________________________

How did you hear about our program?

________________________________________________

MEDICAL WAIVER

I, the parent/legal guardian of __________________________ give permission for the staff at AUBURN GYMNASTICS CENTER to give my child simple first aid or to be transported to a hospital to receive emergency medical treatment.

Who should the gym call in case of an emergency?

1. Name/Relationship______________________________ Phone#_______________

2. Name/Relationship _____________________________

Phone #________________

Doctor’s Name: __________________________________

Phone # _______________

Medical Insurance Co: ____________________________Policy#________________

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT (“AGREEMENT”)

In consideration of participating in the Auburn Gymnastics 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 in the activity. I fully understand that this activity involves risk of serious bodily in 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 “releasees” 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 Auburn Gymnastics 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 “Releasees” 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 “releasees” 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 of the Releasees, I will indemnify, save and hold harmless each of the Releasees from any loss, liability, damage or cost which 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 it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.

I also give permission for Auburn Gymnastics to use images of my child for marketing purposes and for program development.

_______________________________ Date: ____________________

Printed name of participant

________________________________

Signature of Parent or Guardian