Child Name *

First Name

Last Name

Parent Name *

First Name

Last Name

Phone *

(###)

###

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Parental Consent *

By enrolling my child in the program, I acknowledge and agree to the following: ☑︎ I have read, understand and agree to comply with the JCC of Bayonne's Enrichment Policies regarding attendance and billing. ☑︎ Assumption of Risk: I understand that participation in physical activities, including gymnastics, involves inherent risks, and while the program takes every precaution to ensure safety, there is a possibility of injury. I acknowledge these risks and agree to hold JCC of Bayonne, The Gym For Kids, its officers, and instructors harmless from any claims or liabilities that may arise.

I agree

Card Type *

Visa

Mastercard

Discover

American Express

Cardholder Name *

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization *

By checking this box, I authorize the JCC of Bayonne to charge my credit card for the non-refundable monthly program fee and/or any additional fees incurred to my account. (i.e. $25.00 for each declined transaction • $5/minute for late pick-up) I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the JCC of Bayonne in writing of any changes in my account information or termination of this authorization at least 45 days in advance. I certify that I am an authorized user of this Credit Card and will not dispute this scheduled transaction so long as the transactions correspond to the terms indicated in this authorization form.

I agree