Stumpf's Gymnastic Center, Inc.
2187 Wehrle Dr.
Williamsville, NY 14221
716-634-4401
September – June Registration Form
Please complete this registration form and submit the form and the $35.00 registration fee. This registration fee provides excess medical insurance for each student if needed. Please return as early as possible to secure your desired class. Registration is on a first-come-first-served basis. We will not enroll any student without the completed registration form and fee.
Please indicate the class you desire to take:
Class or Level: _________________ Day: ________________________ Time: ___________
Name of Student: ________________________________ Male________ Female________
Address: ______________________________________________________________________
City: ____________________________________________ Zip Code: ________________
Telephone: Home: ________________ Cell: ________________ Other: ________________
E-Mail__________________________________________________________________________
Birth Date: ___________________________ Age: ________________
Do you carry medical insurance? Yes ________ No________
Medical Insurance Name: ____________________________________________________
Does your child have any physical limitations? _________________________________
Did you have your child enrolled last year? Yes ________ No________
I and my child are aware that participating in gymnastics is a potentially hazardous activity. I assume all risks associated with participation in this sport, including but not limited to falls, contact with other persons, and other reasonable risk conditions associated with the sport. All such risks to my child are known and understood by me.
I understand this informed consent form and agree to its conditions on behalf of my child.
Parent's Signature: ____________________________________ Date: ________________
Parents' Names: _______________________ ______________________ Please Print
Fee Paid: Cash __________ Check __________ Date: ___________