Your name
Your phone
Your Email
Are you currently experiencing any of these symptoms Fever and/or ChillsCough or barking coughShortness of breathDecrease or loss of taste or smellMuscle achesExtreme tirednessNone of the above
In the last 14 days have you traveled outside of Canada and been told to isolate? YesNo
In the last 10 days, have you been identified as a close contact of someone who currently has COVID-19? YesNo
Has public health ordered you to be isolating (staying at home)? YesNo
In the last 10 days, have you received a COVID Alert exposure notification on your phone? YesNo
Is anyone that you live, or work closely with, currently experiencing COVID-19 symptoms and/or awaiting a COVID-19 test? YesNo
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Parent/Guardian Name
Participant Name
Participant Date of Birth
Class —Please choose an option—optgroup-Senior CoedFridays 7pm-7:55pm (cost $300 HST included)endoptgroupoptgroup-Junior CoedSaturdays 1:40pm-2:25pm (cost $300 HST included)endoptgroupoptgroup-Preschoolersendoptgroup
Street Address
City/Town
Province —Please choose an option—AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesNunavutYukon
Postal Code
Phone
Your email
Your message (optional)
DISCLAIMER: Listowel Gymnastics Club (“Gymnastics Club”) is not responsible for any injury (or loss of property) to any person while practicing, training, taking class, competing, participating in open gym, special events, demonstrations or shows, or in any other way involved in gymnastics or teams (the “activity”) at Gymnastics Club for any reason whatsoever, including ordinary negligence on the part of Gymnastics Club, its members, managers, agents, or employees
CONSENT: I consent to my/minor’s participation in the activity and acknowledge that I fully understand my/minor’s participation may involve risk of serious injury, illness, or death, including losses which may result not only from my/minor’s own actions, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the activity is being conducted, and/or the rules of play of this type of activity. I understand that if I have any risk concerns, I shall discuss them completely with the staff before I sign this agreement and before my/minor’s participation in the activity begins.
Knowing and understanding the risks involved with participation in the activity, I hereby voluntarily and willingly assume full and complete responsibility for all losses and damages, including injury, illness, and death, resulting from my/minor’s participation in the activity, including transportation to and from the activity. I agree I am financially responsible for any losses and damages resulting from my/minor’s participation in the activity.
WAIVER: In consideration for my/minor’s participation in the activity, I hereby waive all claims or causes of action, including ordinary negligence, against Gymnastics Club, its managers and members, and any of their employees, teachers, coaches, or agents, arising out of my/minor’s participation in the activity wherever, whenever or however the same may occur.
I understand that this waiver is intended to be as broad and as inclusive as permitted by the laws of the Province of Ontario and agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be within the Province of Ontario.
I have read this form and fully understand that by signing this form, I am giving up legal rights and or remedies which may be available to me/minor for the ordinary negligence of Gymnastics Club or any person listed above.
PHOTO & VIDEO RELEASE: I grant consent for my/minor’s picture to be taken or to be filmed while participating in activities at Gymnastics Club. I authorize Gymnastics Club to use and publish images, photographs, pictures, portraits, and audio, video and/or film footage of me/minor in all forms of media and in all manner for publication including, but not limited to, advertising and marketing campaigns, press releases, periodicals, and website use. I hereby waive any right I may have to review, inspect, edit or approve such publication and I release Gymnastics Club from any claims I may have against it for use of such images, photographs, pictures, portraits, and audio, video and/or film footage of me.
Signature:
After registering administration will email you an invoice. Your spot is only secure when the payment is received (etransfer or cash)
