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ZUMBA Fitness Registration Form 2903 Highway 138 East Wall NJ 07719 732-749-3620 NO REFUNDS Participant Information Participant s Name Street Address City/State/Zip Date of Birth Home Phone Sex Male Female Age PARENT/GUARDIAN INFORMATION Parent/Guardian Name E-Mail Relationship Phone Home Cell or Beeper Work ZUMBA Program Schedules Adult Programs Monday 6 00pm-7 00pm Spring Session March 28 2011 April 4 thru April 25 May 2 Pay As You Go 1 Please enroll my child for the program indicated above. 2 I authorize Jersey Shore PAL to utilize pictures of my child in their advertisements. 3 I state that we are the parent/guardians having legal custody of the above child and attest that the information above is correct. 4 I authorize the Director or Director s designee of the above PAL Youth Center to obtain emergency treatment for my child. I further consent to an x-ray examination anesthetic medical or surgical diagnosis or treatment and hospital care to be rendered to the minor at a recognized medical facility under the general or special supervision of a licensed physician or surgeon* 5 I also recognize and understand that the use of any equipment and/or my participation in any activity sponsored by the Jersey Shore Police Athletic League will be done at my own risk knowing that the use of said equipment and/or participation in said activities may subject me to physical injury serious or otherwise. As such I will not hold the Jersey Shore PAL it s members coaching staff/volunteers and directors responsible for any accident or injury that may befall me in the use of said equipment and/or the participation in said activities. Furthermore I will provide the Jersey Shore PAL with a medical certification form from my doctor attesting to my physical ability to participate in certain activities requiring notification* 6 By affixing my signature below I agree and fully comprehend that I am responsible for all payments incurred with regard to this program* Signature of Parent/Guardian Date. 2 I authorize Jersey Shore PAL to utilize pictures of my child in their advertisements. 3 I state that we are the parent/guardians having legal custody of the above child and attest that the information above is correct. 4 I authorize the Director or Director s designee of the above PAL Youth Center to obtain emergency treatment for my child. 4 I authorize the Director or Director s designee of the above PAL Youth Center to obtain emergency treatment for my child. I further consent to an x-ray examination anesthetic medical or surgical diagnosis or treatment and hospital care to be rendered to the minor at a recognized medical facility under the general or special supervision of a licensed physician or surgeon* 5 I also recognize and understand that the use of any equipment and/or my participation in any activity sponsored by the Jersey Shore Police Athletic League will be done at my own risk knowing that the use of said equipment and/or participation in said activities may subject me to physical injury serious or otherwise.

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