PROGRAM PACKET2016 17

FULL SEASON ALL STAR CHEER AND DANCE

WE ARE A Royal FAMILY GYM

Fall tryout info inside!

PAGE 2 Ultimate Athletics | A Royal Family Gym

Welcome to the Royal Family!

Tumbling GuidelinesLevel 1 No tumbling skillsLevel 2 Standing back handspring, round off back handspringLevel 3 Multiple standing back handsprings, round off back

handspring back tuckLevel 4 Standing back tuck, round off back handspring layoutLevel 5R Standing two back handsprings to full, round off back

handspring fullLevel 5 Standing full, round off back handspring double full

Age Guidelines (as of Aug. 31, 2016)

Tiny (all levels) 6 years & youngerMini (all levels) 8 years & youngerYouth (all levels) 11 years & youngerJunior (all levels) 14 years & youngerSenior (levels 1-5R) 10-18 yearsSenior (level 5) 12-18 yearsInternational 14 years & older

Ultimate Athletics offers athletes of all ages and abilities the opportunity to grow and develop under the supervision of professionally trained coaches. There is no better place to experience the world of competitive cheer and dance than Ultimate Athletics. Our teams have excelled at every level since our founding in 2001 having developed the skill and confidence to perform at the highest level of competition. From our coaching staff to our facility, Ultimate Athletics is proud to offer the premier All-Star program in the Midwest. Our 34,000 square-foot building offers all the amenities you associate with a championship organization:

n 4 Full-size floorsn 2 Rod floorsn 2 Tumble tracksn 2 Trampolines into resi & foam pitsn Fitness studion Pro shopn On-site athletic trainern 5Star power tumblingn Dance studio

n Homework arean Chiropractor / massage therapistn Free WiFin State-of-art sound systemn Video surveillance DVR systemn Unobstructed viewing arean Spray tanning servicen Coffee bar and deli

UA coaches are USASF certified and credentialed in the instruction of pyramids, stunts, basket-tosses and tumbling. The following industry guidelines help determine team placement and instructional level.

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Team PlacementCheer athletes will demonstrate their skill in jumps, tumbling, stunting and choreography. Team placement will be based on age and overall abilities across all skill sets. In some cases, an athlete may not have the required minimum tumbling skills to make a certain level team, but possess other skills that would be beneficial to a certain team. Team rosters will be comprised of members whose talents provide the best chances for success at competition.

Dance athletes will be evaluated on flexibility, strength, core Hip Hop movement, tricks and performance ability.

Athletes will receive their team placement and practice schedule at the close of tryouts.

All returning member accounts must be current to tryout.

FALL TRYOUTS Cheer and DanceSaturday, Sept. 10Noon- 1 pm

Tryout Checklist

APPLICATION (pg. 13)

Completed participant waiver and financial contract (pgs. 14-17).

$50 annual registration fee payable on tryout day. We accept cash, check (payable to Ultimate Athletics), VISA and MasterCard

Welcome to the Royal Family!

UA staff will go over program policies and explain what is expected during the 2016-17 season. This is an opportunity for athletes and parents to meet coaches, ask questions and tour the facilities.

You’ll also learn about:n Classes and clinics n Fundraising n Special events n Illinois Dance Conservatory

You must set up your parent portal account and submit any outstanding paperwork and/or fees before your child can begin practices or classes.

Mandatory Parent OrientationSunday, Sept. 11 @ noon (First day of practice)

PAGE 4 Ultimate Athletics | A Royal Family Gym

FULL SEASON All Star CheerMini-Senior Levels

Tuition and Expenses for Fall Start AthletesFall start athletes pick up the cheer season on Sunday, Sept. 11 and continue through March 19, 2017. Regular season tuition covers weekday practices, Sunday practices, extra practices, one tumbling class per week (see tumbling progression below) and open gym during regularly scheduled practice weeks. Tuition is divided into 8 equal installments and is collected on the 1st of every month (with the exception of the first payment due Sept. 15) with the final monthly installment collected on April 1, 2017. Monthly tuition is non-refundable and cannot be prorated for any reason. Teams that secure bids to post season competition will incur additional tuition due April 15. Specialty open gym and holiday or daytime clinics are not included as part of the program.

TABLE A: 2016-2017 Practice and Tumbling Tuition (Mini-Senior teams)

Season Cost Dates # weeks

Regular Season (Fall Start)

$70/week -or-$1680 per season

(Sept. 11- March 19) 24*

Post-SeasonWorlds Teams

$70/week or $420 (due April 15)

Worlds TeamsMarch 20 - April 30

6

Post-SeasonSummit Teams

$70/week or $490(due April 15)

Summit TeamsMarch 20 - May 7

7

* Includes at no cost: 4 hours open gym per regular practice week (Fri/Sat) and all extra team practices

Tumbling Progression Program (level tumbling)All full season all star athletes receive one hour of tumbling per week as part of their all star season. The cost of this instruction is covered by your monthly tuition and you may not opt out.

Level tumbling is designed to keep athletes working toward perfecting their technique and acquiring new tumbling skills. The color-coded curriculum provides clear guidelines on which skills have been mastered and those that still need work. Athletes receive an initial evaluation at tryouts and are assigned a baseline level and color. Shortly before each new session (approximately every 10 weeks), athletes are re-evaluated to assess skill growth.

At each evaluation, coaches provide feedback that includes which classes would benefit the athlete as they push toward the next skill. The entire program is outlined from level 1 all the way though level 5 so there is always a goal to reach. The system is a great way for athletes, and their parents, to keep tabs on the skills that are needed and celebrate new ones that are attained.

Additional expenses (competition, camps, choreo, music uniform, etc.) are covered on page 5.

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PROGRAM COSTS Cheer TeamsFull Season n Mini-Senior

Automatic Payment — Schedule ATuition and Fees Regular Season24 weeks practice/tumble time (Sept-March)

TOTAL $1680

Automatic Payment — Schedule BTeam Fee $100

CompetitionsCompetitions/coaches fees $900

Skills CampGuest instruction for stunting $50

Choreography and MusicWes Haley and music mixing company $200

TOTAL $1,250

Due at Time of Service — Schedule C

Tryout/Annual Registration (May) $50

Uniform and Practice Gear Uniform (if needed) due. Aug. 1 $400*Competition Bow due Oct. 1 $35*Make-up (if needed) due Sept. 1 $35*

NCA/Cheersport (fundraising available)Competiton Fee due Nov. 1 (approx) $165Coaches Fee due Jan. 1 (approx) $100

TOTAL (*some items require additional tax) $785

Other Expenses

USASF Membership (October) $30You will need to log on to the USASF website to register your athlete and

pay the fee. A $10 service charge will applied to your account if you require

UA staff to process this registration for you.

Optional AccessoriesShoes $80-$95*Backpack $85-$110*Warmups $160*(*Approximate cost. Some items require additional tax.)

It is important that you consider lodging, transportation, meals, spectator fees and Disney park admission (if you attend the post season) for your athlete AND your

additional family members when analyzing the true cost of our program.

Each family is required to create an iClass Pro account and provide a checking or credit card account from which all automatic payments will be withdrawn. Payments that are due at time of service must be made prior to the scheduled due date or they will also be subject to automatic withdrawal. Please see payment plans on page 6.

PAGE 6 Ultimate Athletics | A Royal Family GymPAGE 6

NOTES: Summit-eligible teams needing a bid may attend competitions in Indianapolis (January) and/or Ohio (April) at additional cost. You will be provided with all fee amounts and due dates upon final decision to attend.

(*) NCA/Cheersport competition and coaches fees are estimated. We will announce final amounts as soon as they are available.

(**) Worlds and Summit teams attending the post-season will incur coaches fees due on or about April 1.

PICK YOUR PLAN All Star Cheer Tuition and Fees (Mini-Senior)

PREPAY PLAN (10% tuition savings) MONTHLY PLAN

2016-17 AUTOMATIC PAYMENTS DUE AT SERVICE AUTO PAY DUE AT SERVICE

Due Date

Schedule (A) Tuition

Schedule (B) Fees

Schedule (C) Fees Schedule (A & B)

Tuition & Fees

Schedule (C) Fees

Sept. 15 $1512(due Sept. 30)

$1250.00(due Sept. 30)

$366.25

Oct. 1 Uniform & Accessories USASF Fee

$366.25Uniform & Accessories

USASF Fee

Nov. 1*NCA/Cheersport competition fees

(approx. $165)$366.25

*NCA/Cheersport competition fees

(approx. $165)

Dec. 1 $366.25

Jan. 1*NCA/Cheersport

coaches fees (approx. $100)

$366.25*NCA/Cheersport

coaches fees (approx. $100)

Feb. 1 $366.25

March 1 $366.25

April 1 **Post-season coaches fees (TBD)

$366.25**Post-season

coaches fees (TBD)

April 15 Post-Season Tuition if attending: Worlds Athletes = $420 Summit Athletes = $490 Competition fees for Worlds and The Summit are paid directly to the event producers.

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PROGRAM COSTS Dance Teams

Tryout/Annual registration $50

Annual Tuition (all levels) $600

Competition/Coaches Fees $550

Choreography and MusicMini-Junior $100Senior $200

Costume and ShoesMini-Junior $100Senior $150

USASF Membership (October) $30You will need to log on to the USASF website to register your athlete

and pay the fee. A $10 service charge will applied to your account if

you require UA staff to process this registration for you.

Optional ExpensesBackpack $85-$100*Warm-ups $160*

(*some items require additional tax)

Full Season n Mini-Senior

Tuition and Expenses Fall StartFall tryout athletes pick up the regular season Sept. 11 through May 1, 2017. There are 9 monthly payments due on the 1st of each month. The monthly payment covers tuition for weekly practices and extra practices plus competition and coaches fees. Monthly tuition cannot be prorated for any reason and is non-refundable. All teams may have additional competition and coaches fees for extended travel competitions.

Payment Schedule Monthly Payment Choreo/Music Due Nov. 1

Costume /Shoes Due Oct. 1

Mini-Junior $127 $100 $100

Senior $127 $200 $150

n Each family is required to create an iClass Pro account and provide a checking or credit card account from which all automatic payments will be withdrawn. Payments that are due at time of service must be made prior to the scheduled due date or they will also be subject to automatic withdrawal.

n Senior teams may have additional post-season choreography if attending Worlds. Additional fees will be collected.

n Mini-Junior teams will attend a travel post-season nationals competition (ie. Dance Summit or The ONE). Additional fees will be collected.

PAGE 8 Ultimate Athletics | A Royal Family Gym

2016-17 AUTOMATIC PAYMENTS DUE AT TIME OF SERVICE

Due Date TuitionComp/Coach/

Choreo/Team FeeAdditional Fees

Sept. 15 100.00 $50 Registration (due upon tryout)

Oct. 1 100.00 $300 $50 USASF fee

Nov. 1 100.00 $225 (plus tax) uniform (if needed)

Dec. 1 100.00 $300 $35 (plus tax) competition bow

Jan. 1 100.00

Feb. 1 100.00

March 1 100.00

April 1 100.00

PROGRAM COSTS Tiny Cheer

Tuition and Expenses Fall StartFall tryout athletes will pick up the regular season Sept. 11, 2016 through March 19, 2017. Tuition covers two practices and one tumbling class per week, plus open gym during regularly scheduled practice weeks. Tuition is divided into 8 equal installments and is collected on the 1st of every month (with the exception of the first payment due Sept. 15) with the final monthly installment collected on April 1, 2017. Monthly tuition is non-refundable and cannot be prorated for any reason. Specialty open gym and holiday or daytime clinics are not included as part of the program.

Each family is required to create an iClass Pro account and provide a checking or credit card account from which all automatic payments will be withdrawn. Payments that are due at time of service must

be made prior to the scheduled due date or they will also be subject to automatic withdrawal.

AUTOMATIC PAYMENTSTuition $800Team Fee $50Competition/Coaches Fees $450Choreography/Music $100

DUE AT TIME OF SERVICEAnnual Registration Fee $50Uniform (if needed) $225*

Competition Bow $35*

USASF Membership (October) $30You will need to log on to the USASF website to register your athlete

and pay the fee. A $10 service charge will applied to your account if

you require UA staff to process this registration for you.

Optional ExpensesShoes $80-$95*Backpack $85-$110*Warm-ups $160*

(*some items require additional tax)

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CHEER Event Location Mini Levels 1-4 / Level 5R Level 5 (1) Worlds

BidsSummit

Bids

Sunday, Nov. 6 Royal Family of Gyms (Royal Bash) TBD n n n

Sunday, Nov. 13American Cheer Power

(Patriotic Open)Dekalb n n Exhibition Wildcard

Sat./Sun, Nov. 19 & 20 Athletic Championship (GOLD) St. Louis* n n

Sat/Sun, Dec. 3 & 4 Nations Choice (Holiday Classic) Dekalb n n n n

Sat/Sun, Dec. 10 & 11 *WSF Nationals Louisville* n n n n n

2017

Saturday, Jan. 28 Cheersport (Chicago Grand) Dekalb n n Wildcard

Saturday, Feb. 11 CSG (Badger Challenge) Milwaukee n n

Fri-Sat, Feb. 17-19 Cheersport Nationals Atlanta* n n n

Fri-Mon, Feb. 24-27 NCA Nationals Dallas* n n n

Sat/Sun, March 4 & 5The Showdown Grand Nationals

(GLCC) –additional fees Schaumburgn

no extra fees

**Teams needing a

Summit bid

**teams needing a Worlds bid

n n

Sat/Sun, March 11 & 12 CSG (Super Nationals) Rosemont nTeams with

Summit bidsn n

Sat/Sun, March 18 & 19American Championships

(American Classic)Schaumburg

Teams needing a Summit bid

n

Fri-Sun, Mar. 31 - Apr. 2 All Star Games –additional fees Las Vegas* n

Sat/Sun, April 1 & 2American Cheer Power (Midwest

Championship) –additional fees Columbus***Teams needing a

Summit bidn

Sat-Mon, April 29-May 1 Cheerleading Worlds Orlando* Bids needed

Fri-Sun, May 5-7 The Summit Orlando* Bids needed

DANCE Host Event Location Teams Attending Dance Bids

Sunday, Nov. 6 RFOG Royal Bash TBD Monarchs, Empire

Sat/Sun, Dec. 10 & 11 WSF Nationals Louisville Empire Summit/Worlds

2017

Saturday, Jan. 7 UDA Chicagoland Championship Chicago Monarchs Summit

Saturday, Feb. 11 CSG Badger Challenge Milwaukee All dance Worlds/The One

Sat/Sun, March 4 & 5 GLCCThe Showdown Grand Nationals

Schaumburg Monarch, Empire

TBD Dominance (if needed)Summit/Worlds

Sat/Sun, March 11 & 12 CSG Super Nationals Rosemont All Dance The One

Sunday, April 9 Team Champion TOC Chicago Monarchs The One

Sat/Sun, April 22 & 23 The One Cheer & Dance Finals Chicago Monarchs/Empire; Bids needed —

Sat-Mon, April 29-May 1 USASF Worlds Orlando, Fl Empire; Bids needed —

Fri-Sun, May 5-7 Varsity Summit Orlando, Fl Monarchs; Bids needed —

COMPETITION SCHEDULES

* All extended travel competitions require early arrival prior to competition. We will reserve practice space at or near the venue the day before to help athletes prepare for optimal performance. You will receive specific travel instructions and practice times/locations for each of these competitions. Please have your athlete in town at the designated times as practices are not effective without ALL athletes in attendance.

** Summit-eligible teams that need a bid will compete (GLCC, CSG, AC Ohio). Additional competition and coaches fees will be due.

All schedules are considered tentative. Competitions can change at any time for any reason.

We plan on attending either Monsters of Hip Hop or Pulse Dance Convention in Chicago in Winter 2016. Additional fees will be required.

PAGE 10 Ultimate Athletics | A Royal Family Gym

SPECIAL ABILITIES

We are very excited to be entering our ninth season with our Special Abilities Cheer and Dance Programs. Our 2016-2017 season will run until March 2017. Practices are held once a week and led by coaches specializing in the special needs population.

TeamsSpecial Abilities teams are co-ed and are comprised of athletes ages 5 and above with any type of disability. Special needs are defined as a disability characterized by impairment of skills and overall intelligence in areas such as cognition, language, motor and social abilities. We welcome athletes on the entire spectrum of their disability. Athletes in wheelchairs/walkers are also welcome.

We offer two team options:

n Gems All Star competitive cheer team Practices Sunday @ 2-4 pm

n Crystals All Star competitive dance team Practices Friday @ 5:30-7 pm

BuddiesIn the special abilities program, we utilize “Buddies.” Buddies are athletes from other UA teams that are assigned to special abilities athletes to assist in teaching routines. Buddies attend all Special Abilities team practices and participate in all performances and competitions. In order to qualify as a Buddy, an athlete must be 11 years of age and have the maturity to handle the added commitment.

Be active… set goals… and make friends!

Tuition is just $30 per month, with the option to add tumbling for an additional $10 per month.

For more information on becoming an athlete or Buddy, please contact: Jen Gibori, Program Director, jen@ultimateathletics.net

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GYM CLOSINGSNov. 21-26 Thanksgiving BreakDec. 19 - Jan. 1 Holiday Break

IMPORTANT DATESRoyal Bash Nov. 6Team Photos March 6-9Worlds Apr. 29 - May 1Summit May 5-7

CAMP/CHOREOGRAPHYFall Oct. 1 - Oct. 9Winter Jan. 2 - Jan. 15

FAQs

*Each team will be assigned their specific camp dates prior to each block

CROSSOVER POLICIESn Athletes are first and foremost a rostered

member of their primary team.n Athletes must attend all practices of both

their primary and secondary team.n Athletes do not gain additional level tumbling

when participating on multiple teams.n It is at the discretion of coaches/staff to

discontinue having an athlete crossover at any time.

n Multi-program athletes (cheer and dance) receive a 50% discount on their second team tuition.

SPECIAL ABILITIES

PAGE 12 Ultimate Athletics | A Royal Family Gym

PARENT PORTAL

Creating a Family Profile and Registering for Classes in iClass ProIf you are new to UA, please be sure to do this before tryouts.

2. After you have entered your information you will be able to search and register for classes as well as monitor your account throughout the season.

To choose classes from this screen, be sure to use the Programs, Session, and Days drop down menus to help narrow your selections.

BE sure to click the SUBMIT button to apply your selections.

1. Go to the Ultimate Athletics website, ultimateathletics.net, and click on the Parent Portal tab or select it from the dropdown menu on your mobile device. This will take you to iClass Pro where you can set up your family account.

WE ARE A Royal FAMILY GYM

All Star Athlete Application2016-2017

Please complete this form and submit with your $50 registration/tryout fee.

First Name: Last Name:

Street Address: City: State: ZIP:

Home Phone: ( ) Athlete Cell Phone (optional): ( )

Date of Birth Age as of August 31, 2016 Male Female

Medical Conditions/Allergies:

Mother’s Name:

Cell Phone: ( ) Email:

Father’s Name:

Cell Phone: ( ) Email:

Legal Guardian:

Cell Phone: ( ) Email:

Emergency Contact:

Relationship to athlete: Emergency Contact Phone: ( )

Check your program of interest: All Star Cheer All Star Dance

Special Abilities Cheer Special Abilities Dance

/ /

ATHLETE INFORMATION

PARENT /GUARDIAN INFORMATION Please provide at least one (1) responsible party who will serve as primary contact and one (1) emergency contact in case the primary cannot be reached.

Office use only:

Pre-registration confirmation #

$50 registration/tryout fee

Participation Waiver Financial Contract ICP account

Tryout number

Please initial each section and complete with your signature at the bottom of page 2.

Assumption of Risk I the undersigned (if applicant/participant is 18 years of age or older) or parent/guardian of above listed minor applicant/participant acknowledge and fully understand that each applicant/participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death. I hereby release, discharge, covenants to indemnify and not to sue Ultimate Athletics, its affiliated organizations and sponsors, their coaches, and associated personnel, officers, directors, board members, including the owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as ‘releasees’, from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant’s participation in the programs of cheerleading, classes, lessons or any program or activities of Ultimate Athletics and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize.

Consent for Treatment The applicant/participant has received a physical examination by a physician and has been found physically capable of participating in the sport of cheerleading, tumbling, and other gym activities. I hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I accept that all parties herein referred to above as releasees are not to be held responsible for any pre-existing medical conditions or any medical conditions I fail to disclose on my health history. I also agree to save and hold harmless and indemnify above releasees from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasee because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasee.

Photographic Release I hereby authorize Ultimate Athletics and its designated photographers, hereafter referred to as “UA,” to publish photographs taken of myself (if 18 years of age or older) or my minor child for use in UA’s print, online and video-based marketing materials, as well as other UA publications. I hereby release and hold harmless UA from any reasonable expectation of privacy or confidentiality for myself or my minor child associated with the images specified above. Further, I attest that I have full authority to consent and authorize Ultimate Athletics to use such likenesses. I further acknowledge that participation is voluntary and that I waive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other UA publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever. I hereby release Ultimate Athletics, its contractors, its employees and any third parties involved in the creation or publication of UA publications, from liability for any claims by me or any third party in connection with my participation or the participation of my minor child.

Participation Waiver2016-2017

(Page 1 of 2)

This form MUST be completed before participation in any Ultimate Athletics activity.

Participant Name:

Parent/Legal Guardian Name:

Street Address:

City: State: Zip:

Home Phone: ( ) Email:

Medical Conditions/Allergies:

Emergency Contact:

Relationship: Emergency Contact Phone: ( )

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 and The Family Educational Rights and Privacy Act (FERPA) of 1974 require that we guard the privacy of your protected health information. You have the right to confidential treatment of all information and records pertaining to your care; as well as full consideration of privacy concerning your treatment and rehabilitation plan. You also have the right to be advised as to the reason for the presence of any individual during the course of your medical care. If you sustain an injury while participating at Ultimate Athletics, it is important to understand that we may need to discuss your injury with your coaches, parents, and/or other people involved in your care. We may need to discuss issues relevant to your care only under the following circumstances:

1. You have given oral or implied consent through your actions2. You have initialed/signed this authorization form, which permits us to disclose health information.

It is important to know that we will only release the minimum amount of information necessary to protect you.

Participation Waiver 2016-2017 (Page 2 of 2)

Authorization to Disclose Private Health Information I grant permission to the certified athletic trainer(s) and chiropractor, hereinafter referred to as “the practice,” to disclose my personal health information (written and/or verbal), when requested to do so, for the purposes of health care treatment, payment for treatment, or for any other purpose which is permitted or required for law. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereof. I acknowledge and agree that the practice’s privacy notice has been provided to me prior to me signing this consent and that the Notice includes a complete description of the uses and/or disclosures of my Protected Health Information (PHI) necessary for the Practice to provide treatment to me and also, necessary for the practice to obtain payment for that treatment and to carry out health care operations. The practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this consent and has encouraged me to read the Privacy Notice carefully prior to my signing this consent. I further understand that the practice reserves the right to change its privacy practices that are described in its Privacy Notice in accordance with the applicable law. The practice’s Privacy Notice is provided at the time of the patient’s first visit and is always available with the staff at the reception desk. I may also request a copy from this office at any time via US Mail. This Notice of Privacy Practices also describes my rights and duties of this office with respect to my Protected Health Information (PHI) I have read and understand the forgoing notice and all of my questions have been answered to my complete satisfaction in a way that I can understand.

Authorization to Release Private Health Information This authorizes the certified athletic trainer(s) and chiropractor, hereinafter referred to as “the practice,” to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information to the coaches, assistant coaches, and my parents/guardians when deemed appropriate. This information includes injuries or illnesses related to past, present or future participation in athletics at Ultimate Athletics. I understand that the entities that receive the information may not be health care providers or health plans covered by federal privacy regulations, and that the information described above may be disclosed publicly and the information will no longer be protected by those regulations. I understand that Ultimate Athletics will not receive any compensation for its use of the information. I understand that I may inspect or copy any information used under this authorization. I understand that I may revoke this authorization at any time by notifying the practice in writing.

I have read the above waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily.

I the undersigned (if applicant/participant is 18 years of age or older) or parent/guardian of listed minor applicant/participant, acknowledge and agree that I am the parent or legal guardian of the above named minor and therefore have the authority to grant these permissions.

This authorization expires one year from the date it is signed.

Athlete Signature (if 18 years of age or older) Date:

Parent/Guardian Signature: Date:

Please select your primary withdrawal account: ACH Credit Card

ACH Authorization Checking Savings

Name as it appears on account: _____________________________________________________________________

Bank Name: __________________________________________________________________________________________

Account number: ________________________________ Routing number: ________________________________

Credit Card Authorization (A 3% service fee will be charged for using this option.)

Name as it appears on card: _________________________________________________________________________

Card number: ________________________________________________________________________________________

VISA MasterCard Expiration Date: ______________ 3-digit CVC: ____________________

Billing address ________________________________________________________________________________________

City: State: ZIP:

Monthly tuition is due by the 1st of each month and will be considered late after the 5th (exception Sept., due on the 15th)

All athletes must have a credit/debit card on file All past due accounts will be charged a $30 fee for each month late Declined payments will incur a $30 fee to your account There will be no refunds or prorating for team practices, tumbling

classes missed through the season. Additional practices may be added prior to major competitions; no

additional charges for these added hours. There will be no refunds or prorating for practices cancelled due to

holidays, competitions or inclement weather Athletes will not be allowed to participate in practices or

competitions until balance is current on delinquent accounts. Additional fees not included in your monthly tuition installment

include competition, coaches, camp, choreography and music fees.

Sibling discounts—the first child in each family pays full tuition; each additional child receives a 50% discount on tuition.

Athletes are responsible for paying the competition/coaches fees for any alternate that fills their spot when electing not to compete.

Prepay accounts receive 10% tuition discount if the entire regular season tuition and fees are paid by Sept., 30 2016.

All teams may have additional competition and coaches fees for extended travel competitions including but not limited to Cheersport, NCA, Worlds and The Summit.

Two methods of payment are accepted for monthly tuition; ACH withdrawal or debit/credit card.

There is a 3% processing fee for all credit card transactions; no fee for debit cards

Cash or check payments will be accepted for classes, spirit wear, clinics and private lessons

This form MUST be completed in its entirety before an athlete will be allowed to tryout.

FINANCIAL AGREEMENT Please read and initial each of the terms listed below followed by your signature and the date.

ATHLETE INFORMATION

Athlete Name: Parent/Guardian Name:

Street Address: City: State: Zip:

Phone: ( ) Email:

I understand and agree to the above financial policy agreement:

Authorized signature Date

Full Season Financial Contract2016-2017

(Page 1 of 2)

Full Season Financial Contract2016-2017

(Page 2 of 2)

Automatic Withdrawal Schedule by Program

PAYMENT AUTHORIZATION (please select your program below)

Prepay Plan (mini-senior cheer): One (1) tuition payment of $1512.00 and one (1) fees payment of $1250.00 due on or before May 31, 2016.

Monthly (mini-senior cheer): 8 installments for tuition and fees in the amount of $366.25 on the first of the month beginning Sept. 1, 2016 and ending April 1, 2017 (exception, first payment withdrawn on Sept. 15, 2016)

Cheer (Tiny): 8 tuition installments in the amount of $100.00 on the first of the month beginning May 1, 2016 and ending April 1, 2017 (exception, first payment withdrawn on Sept. 15, 2016), plus two (2) payments of $300 on Oct. 1 and Dec. 1 of 2016

Dance (mini-junior): 9 tuition installments in the amount of $127.00 on the 1st of the month beginning Sept. 1, 2016 and ending May 1, 2017 (exception, first payment withdrawn on Sept. 15, 2016), plus two (2) payments of $100 on Oct. 1 and Nov. 1 of 2016

Dance (senior): 9 tuition installments in the amount of $127.00 on the 1st of the month beginning Sept. 1, 2016 and ending May 1, 2017 (exception, first payment withdrawn on Sept. 15, 2016), plus two (2) payments of $150 on Oct. 1, 2016 and $200 on Nov. 1, 2016.

Special Abilities Cheer / Dance: Monthly in the amount of $30 on the 1st of the month beginning Sept. 1 and ending March 1, 2017 (exception, first payment withdrawn on Sept. 15, 2016)

Special Abilities (with tumbling): Monthly in the amount of $40 on the 1st of the month beginning Sept. 1 and ending March 1, 2017 (exception, first payment withdrawn on Sept. 15, 2016)

I agree to have the automatic payments withdrawn from my primary account on the scheduled dates for my selected program. If I am late in making a payment, a $30 late fee will be applied to my account. Additionally, credit cards that decline or bank withdrawals that are returned NSF will incur a $30 penalty fee. I understand that I am liable for and hereby authorize Ultimate Athletics to withdraw funds from my bank account for the purpose of any outstanding fees related to my account and that all fees are non-refundable. Failure to keep your account in good standing may result in the above athlete’s termination from participation in practice or the program as a whole, and an attempt to settle outstanding debt via collections agency at the primary account holder’s expense.

Authorized signature Date

Athlete Name:

SIBLING DISCOUNT: Families with more than one child in the program pay 100% tuition for their first child and 50% tuition for every child thereafter. Please tell us if you are enrolling more than one child at UA. YES! I have children enrolled.

WE ARE A Royal FAMILY GYM

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