CCGI Online Reg. Form
9514 W. PERSHING AVE, VISALIA
(559)651-2244
CLASS NAME, DAY & TIME: __________________ START DATE:_________NEW STUDENT: Y OR N
MOTHER:__________________________ Occupation:_____________________ WK #:________________
FATHER: __________________________ Occupation:_____________________ WK #:________________
ADDRESS:___________________________________ CITY:______________________ ZIP: ____________
PHONE:_____________________CELL/PAGER:_________________ PARENTS SSN#:___________________
1
ST CHILDS NAME: ___________________________________________ Birthday: ______________________2
nd CHILDS NAME: ___________________________________________ Birthday: ______________________3rd CHILDS NAME: ___________________________________________Birthday: ______________________
DOCTOR & INSURANCE:______________________________________________________________________
EMERGENCY CONTACT (NAME & NUMBER): #_________________________ NAME: ___________________
ANY MEDICAL CONDITIONS WE NEED TO BE AWARE OF
: ___________________________________REFERRED BY: _________________________
Email Address: ______________________________________IMPORTANT MEMBER INFORMATION
REGISTRATION
- THERE SHALL BE A REGISTRATION FEE OF $45.00. THIS FEE IS PAID ANNUALLY, AND MEMBERS WILL BE BILLED EACH SUBSEQUENT SEPTEMBER.FEES
ARE DUE AND PAYABLE BY THE 1ST WEEK OF EACH SESSION. IF FEES ARE NOT RECEIVED BY THE END OF THE 1ST WEEK OF EACH SESSION, A LATE CHARGE OF $10 WILL BE ASSESSED FOR EACH CHILD. IF PAYMENT HAS NOT BEEN RECEIVED BY END OF THE 2ND WEEK OF EACH SESSION, THE GYMNAST WILL NOT BE ALLOWED TO CONTINUE WORKING OUT UNTIL ARRANGEMENTS HAVE BEEN MADE. FOR STUDENTS REGISTERING AFTER THE 1ST OF THE SESSION, FEES WILL BE PRO-RATED ACCORDINGLY. UNPAID ACCOUNTS AFTER 90 DAYS WILL BE SENT TO COLLECTIONS.I UNDERSTAND THAT ALL PAYMENTS ARE NON-REFUNDABLE. INITIAL______________
I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF THE SPOT MY CHILD HOLDS IN CLASS UNTIL CCGI IS NOTIFIED IN WRITING THAT HE OR SHE WILL NOT BE RETURNING TO CLASS. INITIAL ______________
I HAVE READ CCGI’S FEE INFORMATION, RULES AND REGULATIONS, AND AGREE TO ABIDE BY THEM.
PARENT OR LEGAL GUARDIAN DATE
I HEREBY AUTHORIZE THE STAFF OF CCGI TO SEEK MEDICAL TREATMENT FOR MY CHILD, IN CASE OF EMERGENCY WHEN I CANNOT BE REACHED.
PARENT OR LEGAL GUARDIAN DATE