Coach form: GymRep/Cheer-Rep
Summer 2017
2520 Blv. Des Entreprises, Suite 108, Terrebonne, Qc, J6X 4J8
Phone: 450-662-9901
Fax: 514-666-0862
Email address: [email protected]
Please fill all sections (please fill out both sides)
A
COACH
Name:
First name:
Addess:
City:
Postal code:
Phone :
Birth date:
Day
Health card number:
/
Month
/
Age:
Year
Province:
(
)
NCCP level:
Expiration date:
Name and address of the club:
Head coach:
Club phone:
B
C
Your email address:
Link:
In case of emergency:
D
C
How didi you learn about GymRep and/or Cheer-Rep
I was a GymRep/Cheer-Rep
Year(s)?:______________
Trought a friend who attended GymRep/Cheer-Rep
Trought an information booth
Brochure
My club
By Internet
CIRCEL YOU LEVEL (For cheerleading)
What level do you coach in cheeleading?
Never coached cheerleading before
F<&'<#.:-'
Never coach
gymnastic
Programme
(Go directly
to next section)
+"
Recreationnal
Défi
Provincial
Senior
Novice
Tyro
Argo
12
34
56
Provincial
P2
P3
J-&$"3%"(4'
T&*&%'
What level do you coach in gymnastics? Gymnast outside Quebec (Level)
P4
P5
1
2
CR1
CR2
CR3
CR3
CR3
E
3
4
5
Élite
Espoir
6 7 8 9 10
National
Réseau National
Novice
Sénior
Base
Avancé
Novice HP
Junior 'HP
Sénior HP
Spécialiste
F
FICHEMEDICAL
MÉDICALE
COACH
STATUS
(1) Are you under medication?
Yes
No
If yes, name of medication and dosage
Yes
(2) Do you sleepwalk?
No
(3) Observations
sur
votre état
de santé:
COCHEZ
OUI EN
CAS
DE PROBLÈMES
ETifPRÉCISEZ.
Cochez
non si correct
(3)
Your state of
health;
Check
yes for
problems
and
specify.
Check no
there is no
problems
Heart
Yes
No
Lungs
Yes
No
Kidneys
Yes
No
Eyes
Yes
No
Ears
Yes
No
Nose
Yes
No
Throat
Yes
No
Mouth
Yes
No
Teeth
Yes
No
Back
Yes
No
Skin
Yes
No
Knees
Yes
No
If problems, please specify :
(4) Do you suffer from allergies ?
Yes
No
(If not, go directly to question 5)
Please specify (type, frequency, seriousness)
Do you carry a dose of adrenalin (Epipen, Ana-Kit) for your allergies?
(5) Do you suffer from chronic or recurrent diseases ?
Astma
Epilespsy
Diabetes
Yes
Yes
No
No
Otitis
Other:
Specify (frequncy, seriousness) :
(6) Were you vaccinated against measles ?
Yes
No
(7) Tetanos shot?
Yes
No
(8) Other medical concerns that we should be aware of (surgery, serious injuries, etc.)
For
administration
Are
you
coming
a group of
10 or
more athletes?
Si oui,
vous
devezwith
communiquer
avec
la personne
en charge des
GymRep
à votreto
club
avoir le numéro
deofréIfinscriptions
so, then it is
MANDATORY
callpour
the personn
in charge
servation etto
nous
fairethe
parvenir
le formulaire
reservation
receive
reservation
number.signeé par la poste
ou par write
courriel
Please
this number in this space.
Please send the form by mail or email as soon as possible!
Oui.
Yes.
No
" Non
M"
#Reservation
de réservation
#
Please indicate 2 preferred choices for your stay in section I and J. In the event that both choices would be unavailable, we
will get in touch with you by email or phone to make arrangements. If you come with a group of 10 athletes or more,
the week must be the same as the groupe.
You must be 18 years old to take advantage of the club program.
I
(#
J
st
2
1
a#
nd
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THE WEEKLY PACKAGE INCLUDES
A 6 night stay at the Camp Boute-en-Train
PLEASE CHECK YOUR
PREFFERED STAY (WEEK(S))
3 meals a day at the Camp Boute-en-Train
Week 1
(according to arrival and departure schedules)
Choice .Choice
July 2nd to July 8th 2017
Week 2
Specialized training in artistic gymnastics and acrobatics bungee system;
July 9th to July 15th 2017
Outdoor activities offered by the Camp Boute-en-Train according to
the availability.
Week 3
July 16th to July 22th 2017
PROGRAMME INTERCAMP
For those staying more than a week, the
Saturday activities (including lodging)and the brunch on Sunday are free of charge.
Week 4
July 23rd to July 29th 2017
Week 5
July 30th to August 5th 2017
CLUB PROGRAM
If you come to the camp as part of a group of 10 or
more athletes from your club, you stay will be free of charge. To take advantage of this
offer, it is mandatory that you have a reservation number.
Please write the reservation number in the right spot on the other side.
Please note: One free coach registration per 10 athletes of the same club, in the same week.
You must be 18 years old the take advantage of the Club Program.
Week 6
August 6th to August 12th 2017
##$&'(T#,"#TUV%N&
YOUR STAY
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EACH WEEK
Before
April 30th 2017
After
May 1st 2017
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COST OF YOUR STAY
P*
2
Please indicate the total amount according to the
number of weeks selected. For club program users
write free and go directly to next section.
R*
3
h*
4
!#
A
-#
B
0#
C
%#
D
T.P.S. (Multiply A by 5%)
T.V.Q. (Multiply A by 9,975%)
Y*
5
U*
6
Add A+B+C
]*
7
i*
8
TOTAL
$
$
$
$
Make cheques and send to:
\*
9
GymRep
TS*
10
.Di;#
Cost
2520, Blv. Des Entreprises, Suite 108
Terrebonne, Qc, J6X 4J8
E(%&'"&
Free for*53'(*
one
,-)$&(%.$)'(L)M*
coach
REGISTRATION REQUIREMENTS AND POLICIES
Paiement: We work on a first paid first
reserved basis. All registrations must be accompanied
by a $200 deposit per week choosen (if 2 weeks = $400, etc.)
You must also include a postdated cheque (dated May 1st
2017), covering the balance ( D -Deposit). Registrations
received after April 30th 2017 will be accepted based on
availability and must be accompanied by a cheque in the full
amount for the week(s) chosen. There will be a $40 service
charge for returned cheques.
REFUND
Any time before April 30th 2017, if accompanied by a letter explaining the cancellation, we will
refund the deposit minus $100 per week of registration.
After May 1st 2017, upon written demand AND accompanied by a medical note, we will reimburse
the full amount minus the deposit (-$200). During Camp, if any injury occurs, we will need a medical
certificate (stating the gymnast cannot exercise at all) and the departure of the gymnast from camp
to issue a partial refund. Refund will be calculated as follows :
Refund
=
(
Total cost- Deposit
Lenght of stay (in days)
)X
number of complete
days missed
I understand that, by their nature, gymnastics and outdoor activities represent a certain degree of risk of injury. No matter what precautions the athletes,
coaches and instructors may take, no matter what safety equipment used, or the height of equipment, no matter what landing surfaces are used, risks cannot
be totally eliminated. In the event of an accident, the directors and the staff of the GymRep/Cheer-Rep Summer Camp and the Boute-En-Train camp will not be held
responsible. The coach must be covered by a personnal accident insurance plan (affiliation to the Fédération de Gymnastique du Québec is mandatory
and covers the gymnastic portion while at the camp).
The GymRep/Cheer-Rep Summer Camp as well as Boute-En-Train camp are not responsible for personnal belongings that may be damaged, lost or stolen.
I, hereby, certify that all medical information given above is accurate. I also authorize the GymRep/Cheer-Rep Summer Camp as well as the Boute-En-Train
camp to give first aid treatment (such as acetaminophen, antibiotic, etc.) to me in case of emergency and take the necessary steps. In such a situation,
I understand that all charges, if any, will be assumed by the coach.
I hereby, accept that, for publicity purposes, GymRep/Cheer-Rep Summer Camp may use pictures and videos taken of my me while staying at camp. I also
understand that I cannot in any ways be paid for this publicity.
I have read and completed both sides of this registration form and I accept it’s conditions and policies.
*
I agree to receive GymRep and Cheer-Rep communications via email and mail (newsletters, promotions, contests, etc.)
V
Coach SIGNATURE
Yes
W Date:
No