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