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  1. 1. LANA’S GYMNASTICS CLUB, Inc. Registration Form STUDENT INFORMATION (PLEASE PRINT) LAST NAME FIRST NAMEBirth Date Age: Sex: School: _______________________ MONTH DAY YEARSerious Injuries If “Yes” Please describe: ________________________________________________Any disabilities If “Yes” Please describe: ________________________________________________Last medical exam: Results:__________________________________________________ MONTH DAY YEAR RESPONSIBLE PARTY INFORMATIONMother: Last Name First NameFather: Last Name First NameHome phone: - - Business phone: - -Address: Apt.City: State Zip -Emergency Contact: - - Name PhoneHow did you hear about Lana’s Gymnastics? Friends: _____________ Newspapers_____________ Flyers Sign Open House Camp Yellow PagePLEASE, DO NOT WRITE IN THIS BOXDay Attending: SUN MON TUE WED THU Program: PRSCL GB BB GP BT PTM TM ____ DNC TKWD MSCTime:Session : Rate : Discount: % Reason:

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