Athlete’s Name: ________________________________________________________________ Age: ____________ Birthday: ____________________ School / Grade: _________________ Parents’ Name(s): _______________________________________________________________ Address: ______________________________________________________________________ City: _____________________________ Zip Code: _______________________ Home Phone: ___________________________ Mom Cell: ___________________________ Dad Cell: ________________________ Email: ____________________________________ Health Insurance: _______________________________ Policy #: ________________________ I, _____________________ the parent or legal guardian of the above named student, do hereby permit the above named student to participate in tumbling, stunting, and dance or any other physical activities with the Louisiana Athletics Cheer gym. By granting permission for above named student to participate in programs with LA Athletics, I assume full responsibility for said student’s participation in any activity at Louisiana Athletics or in which Louisiana Athletics is participating elsewhere. I hereby understand that I am responsible for the above child’s participation costs. I also understand that there will be a $25.00 charge for any NSF checks. I understand that if any charge on my account becomes more than 30 days delinquent or late, I will be obligated to pay interest on the amount outstanding at 18% APR. I also understand that if Louisiana Athletics retains an attorney to collect any past due amount that I will be obligated to pay all attorney fees and cost, including court cost incurred, to collect this debt. Parent’s Signature Date I am registering for: __ Tumbling Class __Cheer camp (June 15/ July 13 / July 27) __ Summer Camp __ CheerNastics __Specialty Class Class: ____________________ How did you hear about us? T-shirt Size: ________________________ Office : _Signature _Emailed _Computer Initials:_____ Day: ____________________ Time: _____________ 17839 Airline Highway Prairieville LA 70737 / 225.744.3777 / http://laathletics.com/