Text Box: Child’s Name _________________________ Child’s Birth Date ___/___/___ (please print clearly) (MM/DD/YY) Parent’s Names _______________________________________________ (please print clearly) Home Phone __________________ Emergency Contact Name & Phone - ___________________________________________________________ Child will attend: □ 1st - 6th grade Full Day Camp $200.00 ½ Day Camp $80.00 □Wk1 □Wk2 □ Tumbling Clinic $75.00 ½ of the camp fee is required for non-refundable deposit. Balance is due the 1st day of camp. Parent’s Signature_____________________________ Date ____________

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Text Box: Open Gym needs no form, just sign up & pre-pay in the office! Text Box: Camper’s Medical Information and Parental Agreement Camper’s Name: ____________________________________ Is the camper allergic to any foods?_____________________________ Insect bites?___________ It’s important that one is healthy and that no past illness or injury could be complicated by physical activity. Since you’re exercising at your own risk, and the Academy assumes no responsibility, you should consult a physician if any doubt exists. Are there any activities in which the camper should not participate? __________________________ Any other medical information we should know: __________________________________________ * In consideration of Berks Gymnastic Academy furnishing training and instruction for your child. I, hereby agree to hold BGA, its employees and administrators harmless for all suits, claims or demands of every nature and character whatsoever arising out of or in connection with the furnishing of such recreational services and training. * In the event that I cannot be reached in case of an emergency, I hereby give permission to the physician selected by the camp director, to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child. Date: ________________ Signature: _____________________________________