Enrollment and Emergency Form (Saline)
Child's Name *
Your answer
Grade *
Your answer
Age *
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
E-Mail Address *
Your answer
Mother's Name *
Your answer
Father's Name *
Your answer
Child's Physician *
Your answer
Physician's Phone Number
Your answer
School *
Your answer
Birth Date *
Your answer
Work Phone Number *
Number you can be reached at during the day in the event of a last minute class change:
Your answer
Cell Phone Number *
Number you can be reached at during the day in the event of a last minute class change:
Your answer
Can we print your number for a Twirlettes roster for twirling business only? *
Please list any allergies or medical conditions we should be made aware of. *
Your answer
Emergency Contacts
In the event your child becomes ill or is injured during class, please notify the following in this order:
Name of Emergency Contact #1 *
Your answer
Phone Number of Emergency Contact #1 *
Your answer
Name of Emergency Contact #2 *
Your answer
Phone Number of Emergency Contact #2 *
Your answer
How did you hear about Twirlettes? *
Consent
I herby acknowledge receipt of the Saline Twirlettes Rules, Guidelines and Information packet, and have read and agree to abide by its contents. I also hereby acknowledge that I have been properly advised, cautioned, and warned by the Saline Twirlettes and Susan Usher, Head Coach, that by participating in the sport of baton twirling my child named above may be exposed to the risk of injury, including, but not limited to, the risk of sprains, fractures, ligament or cartilage damage which could result in temporary or permanent, partial or complete impairment in the use of a limb, brain damage, paralysis, even death. Notwithstanding such warnings and with full knowledge and understanding of the risk of serious injury to my child named above which may result. I give my consent to my child named on this form to participate in the Saline Twirlettes program. Furthermore, I realize that there is no benefit fund and I will assume personal and financial responsibility in the case of injury resulting from participation in this activity. I realize that the Saline Twirlettes does not guarantee the presence of trained medical personnel on site at each activity. The personnel of the Saline Twirlettes are hereby authorized to follow the above outlined plan in the handling of emergency care for my child. If necessary, my child may be taken to Saline Community Hospital for emergency care.
I give Saline Twirlettes permission to use your child’s photographer and/or video footage on promotional pieces or on the Saline Twirlettes web site *
Required
I give permission for my child to be transported in case of change of location, performance change, or other circumstances. *
Required
Electronic Signature *
Please type your full name below as an electronic signature
Your answer
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