Student Information
Name:*

Gender:*

Date of Birth:*
 / 
 / 
Skill Student Possesses:

Parent/Guardian Information
Primary Name:*

Primary Phone:*

-

Primary E-mail:*
Address:*
Secondary Name:

Secondary Phone:

-

Secondary E-mail:
Class Information
First Class:*
First Day of Week:*

First Class Start Time:*
 : 
Second Class
Second Day of Week:

Second Class Start Time:
 : 
In Case of Emergency

Relationship to Student:*

Emergency Contact Name:*

Main Phone:*

-

Waiver and Release of Liability

Inconsideration of allowing the named student to participate in activities in Randy's Tumbling & Xtreme Fun and the use by the student of the premises and property of Randy's Tumbling & Xtreme Fun, the undersigned, acting both for themselves and on behalf of the student, do hereby agree to release and to indemnify, hold harmless, and defend actions, and causes of action whatsoever, arising out of related to  by not limited to any loss, damage, or injury, including death that may be sustained to the student and/or the undersigned while, in or upon the premises under the control and supervision of Randy's Tumbling & Xtreme Fun, its owners, directors, officers, managers, employees, agents, and representatives or while in route to and from the premises, or while at any other premise or place when undertaking activities sponsored by or participated in by Randy's Tumbling & Xtreme Fun, its owners, directors, officers, managers, employees, agents, and representatives.

In the event that the student and/or the undersigned should require emergency medical care or treatment, the undersigned agrees to allow emergency medical care or treatment as deemed necessary by Randy's Tumbling & Xtreme Fun, its owners, directors, officers, managers, employees, agents, and representatives. The undersigned agrees to be financially responsible for any costs incurred as a result of such treatment.

The undersigned hereby acknowledges (a) that he or she have read the foregoing and in particular the "waiver and release" and full understand that it is a release of liability and do hereby sign voluntary; (b) that any undersigned signing as a parent or guardian, in fact the true parent or legal guardian and do hereby give consent without reservation to the foregoing on behalf of this student to participate at Randy's Tumbling & Xtreme Fun; (c) and affirms that he or she is of the age of 18 years or older, and that he or she is freely signing this agreement. He or she certify that he or she have read this agreement, that he or she fully understand its content and that this release cannot be modified orally.

I am aware that this is a release of liability and a contract and that I am signing it of my own free will.

Initials:*

Electronic Signature:*