July 17th–20th 9 am–12 noon AC Flora Gym

REGISTRATION FORM Child’s Age: Child’s Name: Street Address:

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July 17 –20 9 am–12 noon AC Flora Gym

For Ages: 4yrs old to Rising 6th Graders Sponsored by the

Grade completed:

City, State, Zip: Home#:

Cell#:

Parent/Guardian Email: Parent/Guardian Name: (Printed)

Additional Emergency Contact Information Name: Cell#:

Relationship:

Child’s T-Shirt Size T-shirt included with registration. T-shirt not guaranteed for late registrants.

Cost: $75

(includes T-shirt)

Questions: Matt Rhine @ 803.466.8681 Email: [email protected] To register: Mail completed form & check payable to AC Flora Cheer: AC Flora Cheer Clinic, c/o Matt Rhine 203 Whispering Glen Circle West Columbia, SC 29170 Registration deadline is July 10th $10 late fee after registration deadline

Please Check Box

Youth:

Small

Medium

Large

Adult:

Small

Medium

Large

Allergies/Physical Restrictions:

My signature signifies that my child is approved by his/her medical provider to participate and meets physical requirements to participate in gymnastic and cheer activities. I further agree to hold Richland County School District One, AC Flora High School and the AC Flora Athletic Booster Club harmless from any injuries sustained as a result of participation in said activities. /

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Signature

Date

Referred by:

(Cheerleader’s Name)