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Registration Form

Gen Y Debit Card #

Name:

Date of Birth:

Age:

Grade:

School:

Mailing Address:

Email Address:

Cell Phone #:

Parent Contact Name(s):

Parent Phone Number:

Parent Email:

Emergency Contact Information:

Entering & Exiting Club Instructions:

Must leave with a parent or apporved adult My child can leave alone

Name of approved adult(s) if other than parent:

Please initial to confirm Entering & Exiting instructions above:

Please circle RATINGS for Movies your child may watch:

G PG PG13 R

Comments or Concerns:

How did you hear about us?

Food Allergies, Medications, Medical Info (Athsma):

Mandatory Medical Release

I hereby certify that my child is, in good physical condition, and able to participate fully in the programs at Generation Y and that all medical conditions pertaining to the applicant

have been approved for this activity by a medical doctor. All current medications are outlined above. I understand that administration of all required medications is solely the

responsibility of the child or parent and not the responsibility of the staff of Generation Y. I hereby release Generation Y and all its staff and administrators from liability in case of

accident and injury. I understand that our professionally trained instructors will conduct all classes in the safest possible manner. I have fully read and understood this release.

Parent/Guardian:

Date:

Photo Release

I hereby give permission to Generation Y to take/use photographs and/or video of my child for in-studio and/or promotional purposes. All usage will be a positive/family-oriented nature.

Parent/Guardian:

Date:

***Please review our Rules & Expectations with your child/children.

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