Please Write Legibly This Is Very Important Information

ROCKSTAR CHEER JAX

REGISTRATION FORM

**PLEASE WRITE LEGIBLY – THIS IS VERY IMPORTANT INFORMATION**

Athlete Name: / Age:
DOB: / School: / Grade:
Address: / Gender:
City: / State: / Zip:
Lives With:
Referred By:

PARENT/GUARDIAN INFORMATION

(authorized pickup)

Parent/Guardian 1: / Relationship:
Cell Number: (______) / Email:
Parent/Guardian 2: / Relationship:
Cell Number: (______) / Email:
Emergency Contact: / Relationship:
Cell Number: ( ) / Email:

INSURANCE INFORMATION

(IF YOU HAVE NO INSURANCE OR ARE SELF INSURED PLEASE INDICATE SO) :

Insurance Carrier: / Policy #:
Carrier Phone #: / ( ) -
Policy Holder Name: / SSN: / - -
Hospital/Clinic Preference:
Physician Name: / Phone:
Allergies/Health Concerns (Include psychological):

PARTICIPANT AGREEMENT AND ASSUMPTION OF RISK

In consideration of (athlete name) ______’s participation in the services of Rockstar Cheer Jacksonville and its board members, coaches, owners, officers, employees, and all other persons or entities acting on its behalf, I hereby agree to release and discharge Rockstar Cheer Jacksonville, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:

YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF “ROCKSTAR CHEER JACKSONVILLE” USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND ALL RIGHTS OF OTHERS TO RECOVER FROM “ROCKSTAR CHEER JAX” IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE A THE RIGHT TO REFUSE TO SIGN THIS FORM, AND “ROCKSTAR CHEER JACKSONVILLE” HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

Should Rockstar Cheer Jacksonville or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that neither I, nor my child has any mental or physical conditions which may interfere with the safety of this activity, or else I am willing to assume and bear the cost of all risks that may be related, directly or indirectly, by any such condition. In case of an emergency requiring medical treatment, the undersigned hereby authorizes Rockstar Cheer Jacksonville to take the above named athlete to a qualified medical facility or hospital for care and treatment.

1.  I understand and acknowledge that the activity my child is about to engage in poses known risks and unanticipated risks which could result in injury, paralysis, death, emotional distress, or damage to my child, to property, or to third parties. The following describes some, but not all, of those risks: Gymnastics and cheerleading entails certain risks that simply cannot be eliminated without jeopardizing the essential qualities of the activity. Without a certain degree of risk, gymnastics and cheerleading students would not improve their skills, and the enjoyment of the sport would be diminished. Gymnastics and cheerleading exposes its participants to the usual risk of cuts and bruises. Other more serious risks exist as well. Participants often fall off equipment, sprain or break wrists and ankles, and can suffer more serious injuries as well. Traveling to and from shows, competitions and exhibitions raise the possibility of any manner of transportation accidents. In any event, if your child is injured, your child may require medical assistance, at your own expense.

2.  I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity and use of the equipment is purely voluntary. Neither I, nor my child, have been forced to participate. I elect to participate in spite of the risks.

3.  I hereby voluntarily release, forever discharge and agree to hold Rockstar Cheer Jacksonville harmless and indemnify from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with me child's participation in this activity.

4.  Should Rockstar Cheer Jacksonville or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and reimburse them for such fees and costs.

5.  In the event that I file a lawsuit against Rockstar Cheer Jacksonville, I agree to do so solely in the state of Florida, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my or my child’s participation in any activity relating to Rockstar Cheer Jacksonville, I may be found by a court of law to have waived my right to maintain a lawsuit against Rockstar Cheer Jacksonville on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.

MEDIA RELEASE

For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to the photographing of my child and the recording of my child’s voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. I understand that the term “photograph” as used herein encompasses both still photographs and motion picture footage. Further, I understand others, with or without the consent of Rockstar Cheer Jacksonville, may use and/or reproduce such photographs and recordings. I hereby release Rockstar Cheer Jacksonville and any of its associated or affiliated companies, their directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers agents and employees from all claims of every kind on account of such use.

TUITION AND MAKE-UP POLICIES

Tuition is due on the 1st of every month. NO REFUNDS are granted to individuals for a group clinic. Should your child miss a group class/clinic, we will attempt to allow your athlete’s participation in a comparable class with space within 2 weeks of the missed class/clinic. An excused absence form must be submitted in order to make up a class/clinic.

No refunds will be given at any time should your child decide to leave Rockstar Cheer Jacksonville for any reason or if your child is asked to leave for disciplinary reasons; this includes but is not limited to all fees paid to Rockstar Cheer Jacksonville such as unattended competitions and or practice sessions/clinics as well as hotel rooms, bus rides, airfare etc.

We must have a credit or debit card number (Am Exp, Visa or Mastercard) on file for ALL STUDENTS. Our payment policy is as follows: ALL fees must be paid by check, cash, Am Exp, Visa or Mastercard by the 1st of the month for the current month. If payment is NOT received by the 5th of the month your credit or debit card will be drafted. NO EXCEPTIONS. If credit or debit card is declined or check is returned, participation in class will be denied until balance is brought current. Tuition can be paid at the front desk during our office hours. Please keep in mind if you mail your payment, it must be received by the 5th of the month.

SOCIAL MEDIA/ANTI BULLYING POLICY

v  Although we believe in free speech, if you post anything negative regarding Rockstar Cheer Jacksonville from a social media account, you can be asked to leave the program.

v  Remember, when in uniform, you are representing Rockstar Cheer Jacksonville. Any unlawful conduct or language/videos deemed vulgar or inappropriate can be grounds for dismissal from the program.

v  Remember that it is your responsibility to follow the rules when posting content on your personal web site or social media account. You should assume anything you post on your personal account could be read by Rockstar staff, opposing teams, future athletes or coaches. Be smart because you are always "being watched" when it comes to representing Rockstar Cheer Jacksonville. Also, don't forget that there are confidential things we do not want posted to social media. Ask if you are not sure!

v  There is a strict anti bullying policy at Rockstar Cheer Jacksonville. This includes, but is not limited to your activity at Rockstar Cheer Jacksonville. We expect our athletes to maintain a positive image and appropriate interaction with fellow students, athletes, coaches, teachers etc. both inside and outside of our program.

I, the undersigned, do hereby voluntarily submit my application for my child’s attendance and participation with Rockstar Cheer Jacksonville. I do hereby assume full responsibility for all damages, injuries, and/or losses that my child may sustain or incur, while participating, and I hereby waive all claims against Rockstar Cheer Jacksonville, all associated coaches and board members for any claims or injuries my child may sustain.

AUTOPAY AUTHORIZATION FORM

(If bill hasn’t been paid by the 5th of the month, your card will be charged)

STUDENT(S) NAME(S):

CARD HOLDER INFORMATION:

Card Holder Name:
Street:
City: / State: / Zip:

CIRCLE CARD TYPE: VISA MC AMEX

(Options listed above are the only cards accepted)

CC#: / 3-4 digit CVV#:
Expiration Date:

Card Holder Signature: Date: / /

PLEASE MAKE ALL CHECKS PAYABLE TO:

Rockstar Cheer Jacksonville

*Be sure to include your child’s name and what it is for on the check memo line

Parent/Guardian Signature: / Date:
Student Signature (only if 18 or older): / Date: