Loading...

Parental Release Waiver and Assumption of Risk

I am fully aware that gymnastics presents a risk of serious injury, illness, or death, including losses which may result not only from my minor's own actions, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the gymnastics classes, instruction, and/or competition is being conducted, and/or the rules of the gymnastics classes, instruction, and/or competition. I am fully aware of and appreciate the risk and damages that might occur as a result of my minor's participation in or attendance at gymnastics class, instruction, and /or competition.  I acknowledge the contagious nature of certain bacteria and viruses, without limitation, and voluntarily assume the risk that my minor and and our family may be exposed to or infected by such bacteria or viruses by attending Premier West and that such exposure or infection may result in personal injury, illness, permanent disability or death. I understand that the risk of becoming exposed to or infected by bacteria and viruses at Premier West may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Premier West employees, volunteers, and program participants and their families.  Therefore, I hereby voluntarily and willingly assume full and complete responsibility for all losses and damages, including injury, illness, and death, resulting from my minor's participation in the gymnastics classes, instruction, and/or competition, including, if applicable, transportation to and from any competition or off sight class or instruction. I agree I am financially responsible for any losses and damages resulting from my minor's participation in the gymnastics classes, instruction, and/or competition.

 

Nonetheless, I, on my own behalf and of my minor, our heirs, administrators and executors, do hereby release, indemnify and agree to hold harmless, and waive all claims or causes of action, including ordinary negligence, against Premier West, its managers, and any of their employees, teachers, coaches, agents and/or any other person(s) or entities associated with, in any capacity, Premier West from any responsibility or liability for any and all claims, demands, damages, costs, causes of action and expenses (including, without limitation, reasonable attorneys' fees) arising out of or resulting from my minor's participation in or involvement with gymnastics classes, instruction, and/or competition, including without limitation, any personal injury, disability or property damages incurred or sustained by me or my minor during or as a result of gymnastics class. I understand that the participants family medical insurance policy must cover any medical costs incurred in case of an accident. I also authorize photos and videos to be taken of me and/or my minor and/or film to be captured, including audio, while on the premises or at any gymnastics competition.  Therefore, I hereby authorize Premier West to use and publish images, photographs, pictures, portraits, and audio, video and/or film footage of me and/or my minor in all forms of media and in all manner for publication including, but not limited to, advertising and marketing campaigns, press releases, periodicals, and website use. I hereby waive any right I may have to review, inspect, edit or approve such publication and I release Premier West from any claims I may have against it for use of such images, photographs, pictures, portraits, and audio, video and/or film footage of me and/or my minor.

 

In the event of an accident or emergency I AUTHORIZE MY CHILD(REN) TO BE TRANSPORTED TO A MEDICAL FACILITY FOR TREATMENT, at my cost, and will hold you harmless in your management of such accident or emergency. I agree to provide for all medical expenses which may be incurred by myself or my child(ren) as a result of any injury while on your premises or while under your care.

 

I fully understand that my credit card will not be charged until class placement occurs. Upon class placement, my card will be charged tuition(s) plus the annual registration fee of $30.00 (if due).  Then I understand that my credit card will automatically be charged on the 24th of every month following until I provide an email notice by the 20th of the prior month in order to leave class.  After giving proper email withdrawal to PremierGymWest@gmail.com I will not be charged for any upcoming months in the future.   All tuition payments not received by the last day of the month will incur a late fee on the 1st.  Returned check/chargebacks will incur a $35 fee.

 

I understand that this waiver is intended to be as broad and as inclusive as permitted by the laws of the State of Illinois and agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be within the State of Illinois.

 

I do hereby verify that I fully understand and accept the preceding conditions for permitting my minor to participate in gymnastics classes, instruction, events and/or competition.

I Agree

 

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Parent/Guardian #1 *

Cell Phone Parent/Guardian #1 *

Parent/Guardian #2

Cell Phone Parent/Guardian #2
Credit Cards Accepted - Visa, Mastercard, Discover *
Credit Card On File with Premier Gymnastics Academy West (for all monthly classes)

Authorization Agreement for Credit Card Auto-Draft

I/We hereby authorize Premier Gymnastics Academy West, Inc. to make my/our monthly payments from the credit card account listed below: Please Complete Information Below To Pay By Credit Card for monthly tuition.

I understand that by signing up for Credit Card Auto-Draft my monthly tuition will be charged on the 24th of the prior month for upcoming tuition. I also understand that if another form of payment was used before the 23rd of each month the card will not be charged. I understand that if my credit card is declined, I have 3 business days to make another form of payment before a $5 late fee will be added to my account. *
Agree

This authority is to remain in effect until Premier Gymnastics Academy West, Inc. has received an email notification from me/us to revoke the authorization of the account. This email notice to PremierGymWest@gmail.com must be provided by the 20th of the prior month.

Draft automatically each month using the credit card on file for monthly classes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!