Mckeon Dance and Gymnastics  
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(508) 473-8166
mckeondanc@aol.com

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Account Information

Mother's First:      Mother's Last:

Home Phone #      Cell Phone #:      Work #:

Mother's Employer:      Mother's email address:

Father's First:      Father's Last:

Home Phone #      Cell Phone #:       Work #:

Father's Employer:      Father's email address: *

Family Address:      City:      State:      Zip:

Emergency contact name:      Phone number:

Relationship to Student:      Cell #:

 

Health Insurance Carier :      Subscriber# :

Choice of Hospital:      Primary physician:

Medical Conditions:

 

1st Student's Information
Last Name:      First Name:      D.O.B.

Class Name:      Class Day/Time:

2nd Student's Information
Last Name:      First Name:      D.O.B.

Class Name:      Class Day/Time:

3rd Student's Information
Last Name:      First Name:       D.O.B.

Class Name:      Class Day/Time:

 

Liabilty and Release Form (Please read carefully and sign as indicated)

In consideration of allowing the previously-declared participant to begin participation in The McKeon Center activities, while on the premises and property of said Center, the undersigned, being the legal and acting guardian of participant, acting for themselves and on behalf of the participant, release and hold harmless Gym I & II, Inc./ The McKeon Center a Massachusetts Corporation, its owners, officers, employees, and agents of and from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises upon which the McKeon Center is conducted, or any premises under the control and supervision of Gym I & II, Inc./ The McKeon Center, its owners, officers, employees, or agents or in route to or from any of said premises, or while at any premises or place when activities sponsored by or participated in by Gym I & II, Inc./ The McKeon Center, its owners, officers, agents, or employees.

Assumption of Risk

Participation in physical activities can involve motion, rotation, and height in a unique environment and as such carries with it a certain assumption of risk. The undersigned and the participant choose to voluntarily enter upon said premises under the control of said corporation, knowing their present condition and knowing that said condition may become more hazardous and dangerous during the time the participant or the undersigned is upon said premises. The undersigned and the participant voluntarily assume any and all risks of loss, damage, or injury that may be sustained by the participant and/or the undersigned or any property owner by them while on or upon said premises described above.

The corporation may but shall not be obliged to carry insurance on the participant, and the existence of insurance shall not change, alter, or increase the liability of the corporation to the participant and the undersigned or affect the terms of this Release.
In signing this Release, the undersigned acknowledges:

a) That he/she has read thoroughly and understands completely, the terms of Registration and Release and signs it voluntarily.
b) That the undersigned signing as Legal Guardian is, in fact, the true and legal guardian and has the consent of the participant.

Medical Release Form

I hereby declare any physical problems or restrictions. I am also listing any know allergies or special conditions of any kind as well as any medication my child takes.

The undersigned gives permission for the Gym I & II, Inc./ The McKeon Center owners, officers, employees, and/or agents to seek emergency medical treatment for the student in the event they are unable to reach any parent or guardian. The undersigned also agrees that they themselves will be responsible for any financial debt incurred by said action.

WAIVER/RELEASE FOR COMMUNICABLE DISEASES INCLUDING COVID-19 ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT
In consideration of being allowed to participate on behalf of Gym I & II Inc. / DBA McKeon Dance & Gymnastics Center gymnastics and dance program and related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1. Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS (Gym I & II Inc. / DBA McKeon Dance & Gymnastics Center) their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Payment Information
There is an annual registration fee due at the time of registration. This fee is based on the length of class and the number of family members registered. Tuition is due by the first of each month and is based on flat monthly rates. If you should receive five classes during the month instead of four there will be no extra charge although it will be considered a makeup for classes missed while McKeon Center is closed for holidays. We’ve found that during the course of a year this averages out nicely and is a far less confusing payment arrangement for everyone concerned. McKeon Center will send out a statement of account.

If accounts are paid after the tenth of the month there will be a $15.00 late fee applied to the account balance. If, however you need to make different payment arrangements please come to the business office and we’ll be happy to work something out. Accounts that become 30 days overdue will be considered for refusal of services unless other arrangements have been made. There is a $25.00 returned check charge for any checks returned by the bank.

No refunds will be given. A letter of credit will be issued for any credit amount on your account.

*A two-week written notice to the McKeon Center Business Office is required to discontinue a program, otherwise I will be charged for any unattended classes.

By checking this box, I acknowledge that I have read and understand the above information.

Parent/Guardian name:* Date:
* = required

 

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3A Spaceway Lane
Hopedale, MA 01747
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(508) 473-8166
mckeondanc@aol.com