Child’s Name:

 

Age:                                                                   Birth Date:

Address:

 

Home phone:

 

Mother’s Name:

Occupation:

 

Work Phone:

 

Father’s Name:

Occupation:

Work phone:

 

List any medical conditions that we should be aware of:

 

 

Emergency phone:

Emergency contact name:

Insurance Company and policy:

 

I acknowledge that I have enrolled my child for athletic training. I recognize that the activities are strenuous, including motion, rotation and height.  As a condition of accepting my child, I agree to hold nhaags, inc. and all associated harmless and have adequate medical insurance to cover injury, should it occur.  I agree to all of the above and nhaags, inc. payment and enrollment policies.

 VIDEO AND PHOTOGRAPHY
I give permission for a photo or video of my child to be used in and on New Hampshire Academy's webpage and flyers. 

Signature of parent:_______________________________________

Credit Card Information

Exact name of card holder :

 

Card number:             

Visa   / Master card    Expiration date :

 

Signature must appear below:

Signature:                                                                                       Date: