Powerhouse Athletics

ONLINE REGISTRATION

This is the registration form AND MEDICAL RELEASE for regular monthly tumbling classes and/or monthly competitive/performance teams as well as specialty camps and shops. If you do not see the program you wish to sign up for listed at the bottom of the page, let us know! If you have questions about what forms to fill out based on what class or program you are signing up for, please call 244-3363 or e-mail: powerhouseathletics@hotmail.com

*Required fields are marked with an asterisk (*)

***ALL FORMS MUST BE FILLED OUT COMPLETELY IN ORDER TO BE PROCESSED***

*FULL NAME OF PARTICIPANT: *ADDRESS (street, city, state, zip): *DATE OF BIRTH: GENDER:
Male
Female
*PARTICIPANT'S CURRENT AGE: SCHOOL ATTENDING: *PARENTS'/GUARDIANS' NAME(S): *HOME PHONE: CELL PHONE: *PARENT'S WORKPLACE & PHONE #: *EMERGENCY CONTACT NAME: *EMERGENCY CONTACT PHONE: E-MAIL ADDRESS (please provide):

CLASS DESCRIPTIONS

REC CHEER/MTV THUNDER (Ages 5-12)

CHEERLEADING TECH/CHEER TEAM (ages 4 and up)

DANCE TECH/DANCE TEAM (ages 4 and up)

TODDLER TUMBLING (ages 18 months - 4)

BASIC TUMBLING (ages 4 and up)

INTERMEDIATE TUMBLING (ages 4 and up)

ADVANCED TUMBLING (ages 4 and up)

*Please describe the class or program the student will be attending: _________________________________________________________________________________________________________________________________________ I understand that should my child participate in a Powerhouse Athletics program or on a PA team, he or she will engage in a strenuous physical activity and there is a chance of injury or even death. Powerhouse Athletics activities include, but are not limited to, stunting, jumping, tumbling, playing, stretching, running, mounting, dancing, cheering and a variety of other physical activities. I understand the risks and give full permission for the above-mentioned child to participate in said activities and will not hold Powerhouse Athletics, its' owners, coaches or staff liable for accidents incurred during any of the above-mentioned activities. These activities can be performed inside the Powerhouse Athletics official facility and/or in other locations, including, but not limited to, parades, competitions and vehicles in transit to or from official PA activities. I also understand that in the case of an accident my personal insurance will be used to cover medical expenses for my child. *By typing your name here, you understand thoroughly the risks involved with joining Powerhouse Athletics. (Parent/guardian must type in your complete name): *TODAY'S DATE:

THERE IS A $25 REGISTRATION FEE THAT COVERS PROCESSING AND INSURANCE FEES. REGISTRATION FEE WILL BE DUE BEFORE REGISTRATION CAN BE COMPLETED. YOU MAY MAIL IT TO OUR FACILITY OR BRING IT IN IN WITH YOU.

BELOW IS THE MEDICAL RELEASE FORM. PLEASE FILL IT OUT COMPLETELY AND HIT THE SBMIT BUTTON AT THE BOTTOM OF THE PAGE.

MEDICAL RELEASE FORM

TODAY'S DATE: PERSON COMPLETING FORM: PARTICIPANT IS UNDER 18 AND PARENT/GUARDIAN IS COMPLETING FORM (YES OR NO): NAME OF PARTICIPANT: D.O.B.: ADDRESS (street, city, state, zip): HOME PHONE: CELL PHONE: PHYSICIAN'S NAME: IS PARTICIPANT CURRENT ON ALL REQUIRED VACCINATIONS (yes or no): IS PARTICIPANT ALLERGIC TO ANY DRUGS, FOOD, DRINKS OR BUGS (yes or no)? DOES PARTICIPANT HAVE VISION PROBLEMS, WEAR CONTACTS OR GLASSES (yes or no)? DOES PARTICIPANT HAVE ANY PERSISTENT PAIN IN THE BODY AND/OR HEAD (yes or no)? DOES PARTICIPANT HAVE SCOLIOSIS OR OTHER SKELETAL DEFORMITIES (yes or no)?

DOES PARTICIPANT HAVE ANY OF THE FOLLOWING (if so, please list)?

FREQUENT HEADACHES FREQUENT EAR INFECTIONS PROSTHETIC/MISSING APPENDAGES

DIABETES HEART MURMUR OR PALPITATIONS SPECIAL BRACES OR CASTS

HEMOPHILIA/BLEEDING DISORDER FREQUENT DIARRHEA OR CONSTIPATION FAINTING SPELLS/DIZZINESS

ANEMIA FREQUENT RASHES/SENSITIVE SKIN EPILEPSY

ASTHMA FREQUENT NOSEBLEEDS HEARING PROBLEMS(either ear)

LOW OR HIGH BLOOD PRESSURE FREQUENT URINARY INFECTIONS ULCERS, STOMACH PAIN OR HEARTBURN

LIST HERE: PLEASE EXPLAIN FURTHER IF NECESSARY: HAS PARTICIPANT HAD ANY SERIOUS ILLNESSES IN THE PAST 3 YEARS (yes or no)? HAS PARTICIPANT BEEN HOSPITALIZED (yes or no)? HAS PARTICIPANT HAD ANY SURGERIES (yes or no)? HAS PARTICIPANT HAD ANY HEAT-RELATED ILLNESSES (cramps, stroke, exhaustion) (yes or no)? HAS PARTICIPANT HAD ANY BROKEN BONES, SKELETAL OR MUSCULAR INJURIES(including sprains, strains, stress fractures, broken bones, tendonitis and/or cartilage tears) (yes or no)? FEMALES ONLY: Has participant started menstrual cycles (yes or no)? If yes, does she have problems with heavy bleeding, severe cramps or irregular cycles (yes or no)? If any further explanation or information is necessary for us to be completely informed of participant's medical history and/or condition, please explain here:

I, the parent or legal guardian of the above-mentioned participant, give full permission for emergency medical treatment of my child in the event he/she is injured and immediate decisions must be made regarding treatment. I also give my permission to Powerhouse Athletics, its staff and coaches to use their judgement in making decisions regarding emergency medical treatment to my child. I also understand I will be contacted as soon as possible regarding an injury to my child.

PARENT/GUARDIAN SIGNATURE (type name here): TODAY'S DATE: EMERGENCY CONTACT/RELATIONSHIP TO CHILD: FIRST EMERGENCY PHONE CONTACT NUMBER: SECOND EMERGENCY CONTACT NAME AND PHONE NUMBER:

Where Athletes Train.

ONLINE REGISTRATION