ENROLMENT FORM 2010

Last Name: ___Hynes________________Child’s First Name: __Jessica_______________________

Address: ___540 Algona St Tom Price__________________________________________________
Email: _____phatparrot@gmail.com____________________________________________________

Date of Birth: ___9/5/09__________ X Girl  Boy Year level (if applicable)_______________

Phone (H):__9189 3649____________(W):___________________(M):__0447409794_____________
Parent/Guardian 1 (please print):___Michael Hynes_______________________________________
Parent/Guardian 2 (please print):____Elissa Nash_________________________________________
Your expectations are important to us in delivering a quality service. What do you hope your child
will gain through our program? _Confidence, co-ordination, creativity, fun__________________
MEDICAL HISTORY
Please provide details of any medical, physical or intellectual condition that may have a bearing on
your child’s ability, safety or behaviour in class? ______N/A_________________________________
Is your child on any medication, which we should be aware?_____No_________________________
Does your child suffer from any allergies (ie. Medical, bee sting etc.)? ______No________________

If yes, is any action required (please advise)_____________________________________________

Terms and Conditions YES NO

I give permission for my child to be photographed/videoed while participating in any club activities. x
I consent for the photos/video to be used for publicity if required, including the club’s website.
I give my permission for my child to receive medical/ambulance assistance in case of emergency and x
agree to pay such costs incurred.
I understand that I may access my child’s personal information withheld by the club upon request. x

I understand a formal registration policy is recorded and is available upon request. x

The information provided on this form is complete and correct to the best of my knowledge and I x
undertake to advise the Club promptly of any changes that may occur.
I have read and understand this enrolment application and club rules and agree to the terms and x
conditions stated therein.

In accordance with the Privacy Amendment (Private Sector) Act (2000), the information contained within this form will be used
primarily for matters specifically related to participating in gymnastics and/or if a secondary purpose is related to the primary
purpose and one could reasonably expect such use or disclosure. For more information please refer to TPGC’s Privacy policy.

Participation in gymnastics activities carries with it a reasonable assumption of risk.

Parent/Guardian’s Signature: Elissa Nash Date: 6 / 7 /2010

Email to- tompricegymnastics@yahoo.com.au

Office use only:
Receipt Number: Amount Received: Payment Method: Cash/Cheque/Internet Date Received:

Created: 2007 Version 8

Reviewed: May, 2010 1/1