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2202 SE Creekview Dr. Ankeny, IA 50021 Phone:(515)963-0215 Fax:(515)963-3175 www.triadgymnastics.com

1. Student’s Name_______________________________________________________Age______D.O.B. ___/___/___ Sex_____

2. Student’s Name_______________________________________________________ Age______ D.O.B. ___/___/___ Sex_____

3. Student’s Name_______________________________________________________ Age______ D.O.B. ___/___/___ Sex_____

Address____________________________________ City____________________ Zip___________ Phone: ____________________

Mother/Guardian’s Name: ____________________________ Father/Guardian’s Name: __________________________________

Address: __________________________________________ Address: _______________________________________________

(If different from above)City: ________________ Zip: ______ (if different from above) City: ___________________ Zip: _______

Home phone: ________________ Cell #:_________________ Home phone: __________________ Cell #:____________________

E-mail Address: ____________________________________ E-mail Address: _________________________________________

Employer: ______________________ Phone: _____________ Employer: ________________________ Phone: _______________

Would you like us to send our newsletter and special events information to the e-mail address listed above? _____yes _____no

Emergency Contact (other than parent/guardian):__________________________________________Phone #:_________________

Are there any physical, medical, mental, or emotional needs we need to be aware of when working with your child?____ If yes,
please list specific needs: __________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________

Student’s Name: ___________________________Class________________ Day: ____________ Time: ________ Tuition: _____

Fees: Tuition (total):_______________________ Admin. Fee(s):__________________Total:________________

All fees are DUE UPON REGISTRATION to reserve student’s space in the class.

How did you hear about Triad Kids Campus?
(Circle all that apply) Word of Mouth - Yellow Pages - Birthday Party - Newspaper Ad - Field Trip – Website

If word of mouth, referred by:___________________________________________________

CAUTION-ACKNOWLEDGEMENT OF RISK AND WAIVER OF LIABILITY-READ BEFORE SIGNING!

Name of child(ren) participant(s) (if under 18):__________________________________________________________

Name of adult participant/parent: _____________________________________________________________________

I (we) recognize that despite all reasonable precautions implemented for safety, potentially severe injuries including permanent paralysis or death can occur in any activity involving height or motion, including but not limited to gymnastics, tumbling, trampoline and cheerleading. I (we) knowingly and willingly assume all such risks and therefore I consent to the aforementioned person and/or myself participating in Triad Gymnastics, L.C.’s programs. Consequently I (we) hereby for myself, heirs, executors and administrators, do waive and release any and all rights and claims for damages against the owner, operators, coaches and other members of Triad Gymnastics, L.C. from personal injury or accident of any sort or nature suffered by myself or my child by reason of participation or membership in classes, lessons or any programs or activities of Triad Gymnastics, L.C.

In addition, I hereby give my permission to trained medical professionals to administer emergency medical treatment to my child(ren) should sickness or accident occur in my absence.

Parent/Guardian (or self if over 18 years) X____________________________________ Date: ______________

___Payment options: As of September 2008, tuition will be on a monthly basis due on the 1^st of the month and is based on flat monthly rates. If you should receive five classes during the month instead of four there will be no extra charge although it will be considered a balancing factor for those month when Triad Kids Campus is closed for holidays. Over the course of a year this averages out nicely and we hope this will be a far less confusing payment arrangement for everyone concerned. Tuition received after the 10^th of each month will incur a late fee of $15. If tuition has not been received by the 15^th of the month, your child will be dropped from class. If you choose to withdrawal your child from class, please provide 2 weeks written notice. These forms are available at the front desk and on our website.

You have several options for payment: Cash, check, MC, Visa, Discover in person each month; automatic debit from your checking or savings account; or automatic charge to your MC, Visa, Discover. If you would like to have payments processed automatically, please ask the front desk staff for the appropriate forms.

___Joining a class mid-month: Not a problem, as long as space permits. Tuition will be pro-rated relative to your start date.

___Changing classes: We will gladly accommodate class change requests as long as space permits.

___Dropping a class/Missing classes: Registration fees and tuitions are non-refundable. If for some reason, your child needs to discontinue classes after tuition has been paid we will credit your Triad account which can be used for future classes, special events, drop in programs, etc for up to one year after the refund is given. Triad Kids Campus requires a 2 week written notice of any intent to discontinue your child’s enrollment. This gives us an opportunity to allow children who may be on waiting lists to join the class as soon as possible. Triad Kids Campus has a no make-up policy.

___I give permission for Triad Kids Campus to take photographs of my child and have them printed in the newspaper, on Triad’s website and/or in any flyers or brochures promoting Triad programs.