Student's Name_______________________________ Parent's Name_____________________________
Address_____________________________________City________________State______Zip_________
Date of Birth_____________Food Allergies/Special Medical Needs________________________________
Phone#_____________________Cell#____________________Email_____________________________
As parent/guardian of the named student, I give them permission to participate in all the activities at Kids In Motion. I, the
undersigned, understand that Kids In Motion and it's employees shall not be liable for any damages from any personal injuries
sustained by the student in or about the premises, nor is the school liable for loss, theft or damage to my personal property. I
hereby hold harmless Kids In Motion, it's owners, it's employees, instructors, and/or agents from all claims for personal injury,
losses or property damage, regardless of negligence, which may arise out of participation in team activities. I understand that
gymnastics and/or cheer-leading are strenuous sports/arts and that the student is in perfect health and able to undertake
strenuous activities.
_____________________ _____________________________________
Date (Signed) Parent or Guardian
Home Page
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Mail to: Kids In Motion
70 Pine St
New Canaan, CT 06840