|
Enrollment
Form
Name:________________________________________________
Date:___________________
Address:_______________________________________________________________________
Street
City,
State Zip
Code
DOB:________________ AGE:____
Gender:_____ T-Shirt size: S M L
XL
Email:_____________________________________________________________
Home Phone:_______________________ Cell
Phone:_______________________
Work Phone:_______________________
School:_____________________________________
Type of
payment: Cash
______
Check
______ Check Number______________
 Emergency
Contact Information
Name:___________________________________________
Relationship
to you:___________________________________________
Phone:_______________________
Cell Phone:_______________________
Primary Care Physician:___________________________________________
Phone:_______________________
I hereby release
TRI-YON Performance
and all personnel involved from any
responsibility of liability for any injury
or health consequence that may occur from my
participation in this program. I further
assume all responsibility for obtaining
medical or other professional help for any
health problems(s) identified in this
program. In consideration of my
participation in this Program, I certify
that I am fit to participate and waive all
claims for myself and my heirs against
James Yon
and
TRI-YON Performance.
Signature:_____________________________________________
Date:__________________
(Parent or Guardian
must sign if under 18)
Send Enrollment Form
and payment to: Jamey Yon/
TRI-YON
Performance
4224 Arbor Chase rd. Gainesville Ga. 30507 |
