Palaestra Application Form

Last Name *

Parent 1 *

Parent 2

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number *

- Area Code Phone Number

Work Phone Number *

- Area Code Phone Number

Mobile Number *

- Area Code Phone Number

Secondary Mobile Number

- Area Code Phone Number

Primary Email *

Secondary Email

** Registration fees and deposits are non-transferable and non-refundable.

** Please refrain from asking for children to be grouped with siblings or friends.

** Children who are three and older must be potty trained to attend class.

Last Name *

First Name *

Sex *

Birth Date *

- Month - Day Year

Current Age *

This Application is for School Year Palaestra Preschool Only not Summer Palaestra.

Term *

Class Days *

Special Information Concerning Child:

Do you have a second child?

No Yes

Last Name

First Name

Sex

Birth Date

- Month - Day Year

Current Age

This Application is for School Year Palaestra Preschool Only not Summer Palaestra.

Term *

Class Days

Special Information Concerning Child:

Doctor's Name *

First Name Last Name

Doctor's Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Hospital *

All precautions will be taken to prevent injuries. Simple first aid will be administered to all minor injuries and parents and/or doctors will be called when necessary. However, in the event that Crenshaws must make arrangements for emergency medical attention at the time of illness or accident, I hereby authorize Crenshaws to take my child the above Doctor or Hospital. In return for the use, today and on all future dates, of the property, facilities and services (the "Facilities") of Crenshaw Athletic Club ("Crenshaws"), the undersigned, for himself/herself, and on behalf of his/her children, heirs, assigns, and legal representatives, hereby expressly agrees to:

(1) ASSUME ANY AND ALL RISKS TO HIMSELF AND HERSELF AND/OR MY/OUR CHILDREN INVOLVED IN OR ARISING FROM OR MY USE OR MY CHILD'S USE OF OR PRESENCE UPON THE FACILITIES, INCLUDING, WITHOUT LIMITATION, THE RISK OF BODILY INJURY, PROPERTY DAMAGES OR DEATH. I/WE HEREBY AFFIRM THAT I/WE UNDERSTAND THE INHERENT HAZARDS OF ACCIDENTAL INJURY IN CONNECTION WITH ACTIVITIES OR BEING ON THE FACILITIES. I/WE UNDERSTAND THAT ANY ACTIVITY WHICH INVOLVES HEIGHT, MOTION OR WATER CREATES THE POSSIBILITY OF ACCIDENTAL INJURY. I/WE ARE FULLY AWARE OF AND APPRECIATE THE RISK OF CATASTROPHIC INJURY, PARALYSIS, AND EVEN DEATH AS WELL AS OTHER DAMAGES AND LOSSES ASSOCIATED WITH THE PARTICIPATION AT CRENSHAWS AND/OR BEING ON THE FACILITIES.

(2) RELEASE CRENSHAWS AND ALL OF ITS SUCCESSORS, ASSIGNS, SUBSIDIARIES, OFFICERS, DIRECTORS, EMPLOYEES AND AGENTS FROM, AND AGREE NOT TO SUE THEM ON ACCOUNT OF OR IN CONNECTION WITH ANY CLAIMS, CAUSES OF ACTION, INJURIES, DAMAGES, COSTS OR EXPENSES ARISING OUT OF MY/OUR OR MY/OUR CHILD'S USE OF OR PRESENCE UPON THE FACILITIES, INCLUDING, WITHOUT LIMITATION, THOSE BASED ON DEATH, BODILY INJURY OR PROPERTY DAMAGES; WHETHER OR NOT CAUSED BY THE NEGLIGENCE OR OTHER FAULT OF CRENSHAWS, OF ITS AGENTS, EMPLOYEES, OR SERVANTS, WHETHER PAID OR VOLUNTEERS.

(3) INDEMNIFY, HOLD HARMLESS, AND DEFEND, AT MY/OUR OWN COST, CRENSHAWS, ITS AGENTS, EMPLOYEES AND SERVANTS FROM ANY AND ALL LIABILITY, DAMAGES, LOSSES, CLAIMS, JUDGMENTS, COSTS OR EXPENSES, INCLUDING ATTORNEY'S FEES, WHICH IN ANY WAY ARISES FROM MY/OUR OR MY/OUR CHILD'S USE OF OR PRESENCE UPON THE FACILITIES, IRRESPECTIVE OR WHETHER SUCH LIABILITY, DAMAGES, LOSSES, CLAIMS, JUDGMENTS, COSTS OR EXPENSES WERE ACTUALLY OR ALLEGEDLY CAUSED WHOLLY OR IN PART THROUGH THE NEGLIGENCE OF CRENSHAWS OR ANY OF ITS AGENTS, EMPLOYEES OR SERVANTS, WHETHER PAID OR VOLUNTEERS

Read above and Check Below *

I have read and understand this agreement. I also understand a copy of this agreement will be made available for me at my request.

Parent Signature *

Parent Name *

Date *

/ Month / Day Year

at

: Hour Minutes

Have you had a change in address in the last year? *

Additional Comments?

Please Check Below *

I understand that submitting this application does not guarantee the spot in the program and that I need to call Crenshaws at 512-453-5551 to complete the application process.

How did you hear about us? *

Crenshaw Palaestra Application

First Child's Information

Second Child's Information

Emergency Information

Please Read and Sign