Bounce California      REGISTRATION FORM  - ATHLETE INFORMATION

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ATHLETE'S LAST NAME                    FIRST NAME                 MIDDLE INITIAL              GENDER      DATE OF BIRTH

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MAILING ADDRESS

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CITY                                                                    STATE                    ZIP CODE                  HOME PHONE #

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MOTHER/GUARDIAN NAME                                                       MOTHER'S WORK #                 MOTHER'S CELL #

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FATHER/GUARDIAN NAME                                                        FATHER'S WORK #                 FATHER'S CELL #

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E-MAIL                                                                                                                                                                  EMERGENCY CONTACT #

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ALLERGIES TO FOOD OR DRUGS, SPECIAL MEDICATIONS, AND/OR PERTINENT INFORMATION

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FAMILY PHYSICIAN                                                       PHYSICIAN PHONE #

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INSURANCE PROVIDER AND POLICY #

How did you hear about us? ____Word of Mouth ____Yellow Pages ____Birthday Party ____Other

If "Word of Mouth," who were you referred by?: ________________________________________________                                                            

 

THE NAMED CHILD HAS MY PERMISSION TO ATTEND BOUNCE CALIFORNIA PROGRAM.

I CONFIRM THAT HE/SHE IS IN GOOD HEALTH. 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 AND EMERGENCY ROOM STAFF LICENSED UNDER THE PROVISIONS OF THE MEDICINE PRACTICE ACT OR A DENTIST HOLDING A CURRENT LICENSE TO OPERATE A HOSPITAL FROM THE STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH. IT IS UNDERSTOOD THAT THIS AUTHORIZATION IS GIVEN IN ADVANCE OF ANY SPECIFIC DIAGNOSIS, TREATMENT OF HOSPITAL CARE WHICH THE AFOREMENTIONED PHYSICIAN IN THE EXERCISE OF HIS BEST JUDGMENT MAY DEEM ADVISABLE. IT IS UNDERSTOOD THAT THE TREATMENT WILL NOT BE WITHHELD IF THE UNDERSIGNED CANNOT BE REACHED. I UNDERSTAND THE RISKS INVOLVED WITH ACROBATIC MOVEMENT AND AGREE TO HOLD HARMLESS BOUNCE CALIFORNIA, ITS PROGRAMS AND THEIR EMPLOYEES AND CONTRACTORS IN THE EVENT OF INJURY OR DEATH. THIS AUTHORIZATION IS GIVEN PURSUANT TO THE PROVISIONS OF SECTION 25.8 OF THE CALIFORNIA CIVIL CODE.

 

 

I agree to make full term payment until I have notified Bounce California in writing of my intentions to cancel.

 

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Signature                                                                                     Date

PARENT SIGNATURE                                                                PRINT NAME                                        DATE