Believers In Motion Enrollment and Waiver
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Students Name *
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Date of Birth *
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Age *
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Street Address *
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City *
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State *
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Zip Code *
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Home Phone *
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Cell Phone *
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Emergency Contact Name
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Emergency Contact Phone Number *
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Emergency Contact Relationship *
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Emergency Contact #2 *
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Emergency Contact Name *
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Emergency Contact Phone *
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Emergency Contact Relationship *
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Doctor's Name *
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Doctor's Phone Number *
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Dental & Medical Care Authorization: I do hereby authorize a staff member of Believers in Motion to request to consent to any reasonable necessary medical or dental examination or treatment, including anesthesia, surgical and hospital care, to be rendered to the above named student on the recommendation and supervision of any dentist, physician or surgeon licensed to practice medicine by any state. *
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Picture Use Permission: I give permission to Believers in Motion to take pictures of above named student and use them solely for the purpose of their web site or affiliate display. For use on the website, the names of the participants will not be posted in order to insure the safety of the student. *
Believers in Motion Gymnastics, self-Defense, and Tumbling is not responsible for any lost/stolen articles, or damages to personal property brought to any operating site or event venue of Believers in Motion. *
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