Home Phone #
Cell Phone #:
Mother's email address:
Home Phone #
Cell Phone #:
Father's email address: *
Emergency contact name:
Relationship to Student:
Health Insurance Carier :
Choice of Hospital:
1st Student's Information
2nd Student's Information
3rd Student's Information
Liabilty and Release Form (Please read carefully and sign as indicated)
In consideration of allowing the previously-declared participant(s) to begin participation in McKeon Center activities, while on the premises and
property of said Center, the undersigned, for themselves, and/or 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., a Massachusetts Corporation D/B/A McKeon Dance & Gymnastics
Center, 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 McKeon Center is conducted, or any premises under the control and supervision of Gym I & II, Inc., a Massachusetts
Corporation D/B/A McKeon Dance & Gymnastics 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., a Massachusetts Corporation
D/B/A McKeon Dance & Gymnastics 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(s) 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(s) voluntarily assume any and all risks of loss, damage, or injury that may be sustained by the participant(s) 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(s), 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 either for themselves, or as Legal Guardian is, in fact, the true and legal guardian and has the
consent of the participant.
The undersigned gives permission for the Gym I & II, Inc., D/B/A McKeon Dance & Gymnastics Center, owners, officers, employees, and/or agents to seek emergency
medical treatment for the participant(s) 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.
Occasionally the McKeon Center uses photos or video of its students in print ads, on its website, or other marketing mediums. I understand that my child’s likeness
may be used in such advertising. These images will be used for McKeon Center purposes only, and will not be given or sold to outside companies or
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 grounds for
collections action. There is a $25.00 returned check charge for any checks returned by the bank. I understand that if my check is returned by the bank, or I am late
with payments, that McKeon Center will require automatic credit or debit card payments from that point forward.
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.
* = required