Carp Ladies Recreational Gymnastics Registration Form

To register please fill out the form below.

If you have any problems, please contact Dasa Lelli at 613-592-5202 or at dlelli@rogers.com.

Class Information

1 Class a week (select 1 option)	2 Classes a week (select 1 option)	3 Classes a week
Monday 9-10:30AM Wednesday 9-10AM Friday 9-10:30AM	Monday 9-10:30AM and Wednesday 9-10AM Monday 9-10:30AM and Friday 9-10:30AM Wednesday 9-10AM and Friday 9-10:30AM	Monday 9-10:30AM, Wednesday 9-10AM and Friday 9-10:30AM

Personal Information

Last Name:	First Name:	Age:

Name Commonly Used: (if different from above)	Birth Date:

Street Address:

City:


Province Postal Code:	Home Phone: ()

Primary Contact
In the event of an emergency, KRSG will attempt to reach the primary contact first. Information from KRSG will be sent to the primary contact via email.

Last Name:	First Name:

Day Phone: ()

Evening Phone: ()

Mobile Phone: ()

Email address:	Relationship to Gymnast:

Secondary Contact

Last Name:	First Name:

Day Phone: ()

Evening Phone: ()

Mobile Phone: ()

Email address:	Relationship to Gymnast:

Medical Information

Are there any medical, family circumstances, or religious requirements of which the coach should be aware?

Yes No

If yes, the coach will arrange a private interview.

Consent of Participation and Waiver

	By checking the box to the left and submitting this form, I acknowledge that I am aware that there are risks associated with gymnastics. I warrant that the participant named on this information form, is physically fit to participate in gymnastics. I declare that I have accurately disclosed all information regarding physical, mental or medical conditions affecting the named participant and acknowledge that this information may be used for Kanata Rhythmic Sportive Gymnastics (KRSG)/ Gymnastics Ontario’s (GO) use in the delivery of a gymnastic program. I acknowledge that there is potential risk for injury involved in training and competing in any sport. I understand that GO has tried to create a safe and controlled environment for participation and that KRSG has established rules for participation on and about the gymnastic area that must be followed by the participant. I understand that failure to comply with any of the policies and rules of KRSG and/or GO may result in the suspension or termination of membership. I waive the rights of the participant to damages or other costs in the event injury is caused due to participation in gymnastics or other involvement with the KRSG Club and/or GO.

	By checking the box to the left and submitting this form, I hereby give permission for emergency medical treatment to be administered, as may be determined in the reasonable discretion the Personal Coach/Team Manager. It is understood that whenever reasonably possible, relatives will be contacted and informed of the problem, diagnosis; treatment required and anticipated medical results.

By submitting this form, I acknowledge that I am aware and agree with KRSG’s privacy policy as stated below.

Registration Information Privacy Policy: The KRSG Club uses the information collected at registration for its own purposes associated with the operation of the club and its registration processes with Gymnastics Ontario. Information is not released to other third parties for any reasons without the written permission of the club members.

I understand that is my responsibility to ensure that the information on this form is kept current and I will notify the KRSG of any changes immediately.

When the SUBMIT button below is pressed, information entered above will be submitted to KRSG via standard e-mail over the Internet. If you prefer, you can print out the form and submit it via regular mail, sending it to Dasa Lelli, 38 Equestrian Dr, Kanata, ON K2M 1E8.

Last Updated on Thursday, September 06, 2007