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The child(ren) participating at AGA Northwest have my permission to attend American Gymnastics Academy Northwest (AGA NW). I understand there is an element of risk involved in learning gymnastics including serious injury or death. I confirm that my child is in good health and that he/she has passed a physical examination by a doctor in the past 6 months. I promise I have read and understand the "Signs and Symptoms" checklist. I agree to taking my child's temperature prior to class. Should my child have a temperature that exceeds 100 degrees, I will not bring them to AGA Northwest. I give my permission for AGA NW officials to call a doctor, and call the persons listed on the family registration form, in the event of an emergency. I will in no way hold AGA NW, its officials or staff members, responsible for any possible illness, accident, or injury which might occur in class training. Nor will AGA NW be held responsible for any illness, accident, or injury that might occur traveling to and from the AGA NW facility.

By entering this facility, you are aware that you agree to fully accept all known and unknown risks, including the potential risk of exposure to respiratory illnesses such as the coronavirus (COVID-19). The coronavirus is primarily transmitted via exhaled respiratory droplets, most often through coughing and sneezing. These droplets can travel up to six feet and are more commonly transmitted between persons rather than from equipment to persons. Although we regularly sanitize our equipment and presently are using enhanced cleaning methods and enforcing social distancing in our facility, you understand that you may be exposed to the coronavirus or its symptoms through no fault of our own. Known coronavirus symptoms include fever, coughing, shortness of breath, pneumonia, kidney failure, and may include other symptoms, stroke or even death (collectively "Symptoms"). You understand and agree that you will hold us harmless and you will not hold us liable for any real or perceived Symptoms of COVID-19 or any other disease, illness, or condition, nor for exacerbating any existing symptoms, and you fully agree to accept all risks of entering the facility, usingthe equipment, working with personal trainers, attending classes, and/or interacting or being exposed to other members.

I do hereby authorize and consent to any x-ray, examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff licensed under the provisions of the Medicine Practice Act or a dentist licensed under the Dental Practice Act and on the staff of any acute general hospital from the State of Washington. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.

I understand and will comply with AGA Northwest’s Program Guidelines and Policies. I also understand these guidelines are posted in the facility and I will be emailed a copy of these guidelines upon class registration.

I herby give my permission for images of my child to be used for the sole purpose for AGANW promotional and marketing materials. I understand the last name of my child will not be posted.

I understand my child's trial class is a $10 fee. This fee will be applied to my account as a credit, should I enroll my child. I understand AGA Northwest must have a card on file at all times during my child's participation in the program. AGA Northwest will not use my card without verbal or written authorization. I understand AGANW will unenroll my card from the billing profile should I choose to not participate in the program. I understand, there is a $40 enrollment fee (unpon registration) as well as my monthly tuition. Monthly tuition is due on the 1st of each month. The card I'm providing will be used to fulfill my financial obligation. I understand that if my bill is not paid by the 5th, a late fee of 10% of the owed amount will be added to my account. I understand I am responsible to inform AGA Northwest by the 20th of the month prior if I wish to discontinue their program. Should I not inform AGANW of our dis-enrollment by the 20th of the month, I will be charged for the following month's tuition. I understand it is my responsibility to check my monthly charges through the parent portal or request them with the office personel. I understand there are absolutley no refunds given after tuition has been processed. AGA is a year-round program in which 12 monthly payments are made, starting at the time of enrollment. I understand I have the option to pay our fees in full, quarterly, or monthly. 

 

First Child's Name Name

First Name*

Last Name*

Phone*
First Child's Name Date of Birth*
I certify that I am 18 years of age or older
First Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
First Child's Name Signature*
Second Child's Name Name

First Name*

Last Name*
Second Child's Name Date of Birth*
Second Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Third Child's Name Name

First Name*

Last Name*
Third Child's Name Date of Birth*
Third Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Fourth Child's Name Name

First Name*

Last Name*
Fourth Child's Name Date of Birth*
Fourth Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Fifth Child's Name Name

First Name*

Last Name*
Fifth Child's Name Date of Birth*
Fifth Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Sixth Child's Name Name

First Name*

Last Name*
Sixth Child's Name Date of Birth*
Sixth Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Seventh Child's Name Name

First Name*

Last Name*
Seventh Child's Name Date of Birth*
Seventh Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Eighth Child's Name Name

First Name*

Last Name*
Eighth Child's Name Date of Birth*
Eighth Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Ninth Child's Name Name

First Name*

Last Name*
Ninth Child's Name Date of Birth*
Ninth Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Tenth Child's Name Name

First Name*

Last Name*
Tenth Child's Name Date of Birth*
Tenth Child's Name Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Billing Information
Are you in the military? *
Yes
No

Billing Information: Name on Card *

Card Number *

Expiration Date *

CVV # *

Billing Zip Code *
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. By finalizing this document, you're verifying the information you've provided is correct. Any information falsely provided will result in penalty. Each person at AGA Northwest is required to provide card information to be an active member in our program. Your card will be charged a $10 fee for the trial class. This will be applied to your account as a credit towards future charges, should you enroll in our program. This card will only be used if you verify your child's enrollment.


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