Fill and Sign the Medical Information Release

Medical Information, Athletic Waiver and Release for Gymnastics and Cheerleader School Student Name _______________________________ Date ___________ Parent Name ________________________________________________________ Parent Address ______________________________________________________ Who should be called in case of an emergency? 1. Name ______________________________________________________ Relationship _______________________________________________ Phone ______________________________ Alt. Phone __________________________ 2. Name ______________________________________________________ Relationship _______________________________________________ Phone ______________________________ Alt. Phone _______________________ 3. Doctor’s Name ___________________ Address _____________________________ Phone ____________ 4. Medical Insurance Co. ________________________________________ Group Number ______________ Phone ____________ 5. Please answer the following about your Child. If you answer “Yes,” please describe briefly. 6. Previous gymnastics experience? ____ No ____ Yes  ________________________________________________________ 7. Allergies or intolerance to food or medication? ____ No ____ Yes  _______________________________________________________  Medications currently being taken? ____ No ____ Yes  _____________________________________________________________ 8. Previous injuries or illnesses? _____ No _____ Yes  _______________________________________________________________ 9. Restrictions or special considerations? ____ No ____ Yes  _______________________________________________________________ 10. I, the undersigned parent of ________________ (name of Child) , hereinafter called Child , fully understand that the staff members of the ____________________ (Name of School) , hereinafter called School , are not physicians or medical practitioners of any kind. With the above in mind, I hereby release the School staff to render first aid to my Child in the event of any injury or illness, and if deemed necessary by the School staff to call our doctor and to seek medical help, including transportation by a Staff member of the School , or its representatives, whether paid or volunteer, to any health care facility or hospital, or the calling of an ambulance for said Child should the School staff deem this to be necessary. 11. The staff of School recognizes its obligation to make students and their parents aware of the risks and hazards associated with the sport of gymnastics, trampoline, tumbling, cheerleading, and dance. Gymnastics, trampoline, tumbling, cheerleading, and dance can be dangerous and can lead to injury. Students may suffer injuries, possibly minor, serious, or catastrophic in nature. Parents should make their Children aware of the possibility of injury and encourage their Children to follow all the safety rules and the coaches’ instructions. With the above in mind, and being fully aware of the risks and possibility on injury involved, I consent to have my Child or Children participate in the programs offered by the School. I, do hereby fully and forever release, discharge, indemnify and agree to hold harmless School, its agents, servants and employees from any and all claims, demands, damages, rights of action of causes of action, present or future, whether the same be known, anticipated or unanticipated, resulting from or arising out of participation in gymnastics, trampoline, tumbling, cheerleading, or dance instruction, or open workouts or in the case of any exhibition, competition, or clinic in which Child may participate while traveling to or from the event. 12. I also affirm that I now have and will continue to provide proper hospitalization, health, and accident insurance coverage which I consider adequate for both my Child’s protection and my own protection. 13. I also understand that it is the parents’ responsibility to warn the Child about the dangers of gymnastics and injury. The parent should warn the Child according to what the parent feels is appropriate. School will only warn the Child through “safety messages” and our teaching style and progressions. WITNESS my signature on this the ____ day of ___________, 20___. ______________________________ (Printed Name of Parent or Guardian) ______________________________ (Signature of Parent or Guardian) (Acknowledgment form may vary by state) State of _____________________ County of ___________________ Personally appeared before me, the undersigned authority in and for the said County and State, on this ________________ (date) , within my jurisdic tion, the within- named _____________________ (Name of Parent) , who acknowledged that he executed the above and foregoing instrument. __________________________ NOTARY PUBLIC My Commission Expires: ____________________