Gymnast Factory - 2520 Albans - Houston, Texas 77005 - Phone: 713 527 8753 - Fax: 713 527 9490 Tuition Classes

Registration to the Gymnast Factory is easy. Save time by filling out the form below, or if you prefer, you can print* out the registration form and fax it to us at (713) 527-9490.

*Note: The free Acrobat Reader is required to view this form. You can download it here.

Student’s Name:
Birthday:

Home Address:

Home Phone:

City:

ZIP:


Family Information

Father’s name:

Work Number:

Mother’s name:

Work Number:

E-mail address:

Emergency Contact:

Phone Number:

Doctor’s Name:

Phone Number:


Enrollment Information

Semester:

Enroll in Class:

SUMMER SESSION 2012 COMING SOON!

DAY/TIME and/or SPECIAL INSTRUCTIONS:

MARCH 12th MARCH 13th MARCH 14th MARCH 15th MARCH 16th




*NOTE: Please refer to class schedule for days and times of selected class.


PAYMENT
I am aware that I will be charged a $25 fee for a returned check.

Please charge my tuition to my credit or bank debit card.

Credit / Debit Payment Information
Card Type:
 Card Number:
 Expiration:

This authorization will remain in effect until the company has received written notification from me (or either of us) at the address listed above that is to be termiinated in such manner for the company to act on it.

I (We) authorize Gymnast Factory to initiate debit entries to my (our) account with the depository named below. If the company erroneously debited funds from my (our) account, I (We) authorize the company to initiate necessary credit entries not to exceed the total of the original amount debited for the entry in question.

I (or either of us) have the right to stop payment of a debit entry by notification to my depository 3 business days before my account is charged. After my account has been charged, I have the right to have the amount of an erroneous debit immediately credited to my account my depository, provided I (We) send written notice of such debit entry in error to depository within fifteen days following issuance of account statement or 60 days after posting - whichever occurs first. A $25 fee will be charged to closed debit accounts.

AUTHORIZATION AND RELEASE

AUTHORIZE GYMNAST FACTORY TO CONSENT TO MEDICAL TREATMENT FOR MY CHILD WHEN I CANNOT BE REACHED TO SO CONSENT. NO PRIOR DETERMINATION OF LIFE THREATENING EMERGENCY OR DANGER OF SERIOUS OR PERMANENT INJURY RESULTING FROM DELAY OF TREATMENT NEED BE MADE UNDER THIS AUTHORIZATION. EXCEPTIONS TO AUTHORIZATION ARE AS FOLLOWS:

I AM FULLY AWARE THAT ANY ACTIVITY INVOLVING MOTION OR HEIGHT CREATES THE POSSIBILITY OF SERIOUS INJURY AND I FURTHER AGREE TO HOLD GYMNAST FACTORY INC. AND IT'S AGENTS HARMLESS FOR ANY INJURY RESULTING EXPENSE. I RELEASE AND DISCHARGE ANY AND ALL RIGHTS AND CLAIMS AGAINST GYMNAST FACTORY INC.

 

Parent / Guardian:
Date: