Gymnastics Enrolment Form

Personal Information

First Name of Child *

Last Name of Child *

Date of Birth *

First Name of Parent/Gaurdian *

Last Name of Parent/Gaurdian *

Address *

Home Phone

Work Number

Mobile *

Email Address *

Enrolment Information

Program you are enroling in: *

Ed Gym

Preferred Day's

Time

Medical History

Does your child have any medical conditions we should know about? *

YesNo

If your child has a medical condition, please provide details:

Does your child have allergies? *

YesNo

If your child has allergies, please provide details:

Is your child an asthmatic? *

YesNo

If your child is asthmatic, please provide details of their treatment plan:

General Information

Is there anything you feel the instructors need to know about your child?

During the course of the program, film footage and photographs may be taken of the people participating in the Y Canberra Region Gymnastics programs. The Y Canberra Region requests the right to use filming and photos in the promotion of a program and the associated messages of participation in the Y Canberra Region promotions throughout the Canberra and Queanbeyan region.

I consent that my child’s photograph/footage may be reproduced in print and electronic media for the Y Canberra Region promotional activities. I understand that:

My child’s photograph/footage may be used more than once in a variety of the Y Canberra Region printed publications relating to; promotional activities, advertising & brochures.
My child’s photograph/footage may be presented in a variety of formats including digital on social media sites and electronically on the Y Canberra Region and The Y Canberra Region associated websites.
My child’s first name may be used in some cases to describe the content of the photograph/footage.
I will not receive any royalties from the Y Canberra Region for the use of my child’s photograph/footage, either locally or internationally.
I may contact the Y Canberra Region in writing to request that my child’s photograph no longer be used in future print or electronic media. On request the the Y Canberra Region will cease to use my child’s photograph but may not be able to withdraw all current media (already featuring the photograph) from circulation.
The Y Canberra Region will use my child’s photograph/footage respectfully and will not alter it in anyway.

Declaration

In consideration of your acceptance of this application, I hereby agree that the Y Canberra Region and it's officers, staff and agents shall be released from, and shall not incur any responsibility or liability whatsoever, for any accident or injury sustained by me or any other member of my family included on this application or for any damage of loss of my family's property. I further authorise you to obtain at my cost medical or ambulance assistance in case of emergency involving me or any member of my family. I agree to abide by the policies and procedures as adopted by the Y Canberra Region. I understand that I will incur a commission fee if my account is forwarded to a debt collector. *

The Y Canberra Region is committed to Safeguarding Children and Young People, providing a child-safe organisation and works in partnership with the Australian Childhood Foundation. I acknowledge the YMCA Safeguarding Children and Young People Policy and agree to adhere to the Safe Behaviours Policy while in attending and/or participating in gymnastics programs.

*

I acknowledge that I cannot take photos during the class unless permission is given from the instructor. Where permission is given, no other children are to be captured in the photo. *

I acknowledge that my/my child enrolment can be cancelled at anytime if I or my child do not abide by YMCA policy and/or procedure.

*

Signed

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Date: