Green Mountain Gymnastics
Kids Night Out
Waiver/Release Form 2008/2009

Name of Child:

 DOB:

   Male
  Female
Address:

City:

 State:

 Zip:

Telephone         Parent:

 Spouse/Partner:

Cell or Pager     Parent:

 Spouse/Partner:

Parents Names:

e-mail address:

Emergency Contact Name:

Emergency Contact Phone:



**Please note: This form will be kept on file and will cover all GMG "Kids Night Out" programs from September 1, 2008 - August 31, 2009

Parent/Guardian Waiver Release Form: I fully understand that Green Mountain Gymnastics Staff members are not physicians or medical practitioners of any kind. With that in mind, I hereby release Green Mountain Gymnastics to render temporary first aid to my child in the event of any injury or illness, and if deemed necessary by the GMG staff to seek medical help and/or call an ambulance. You agree that you are aware that your son/daughter will be engaging in physical exercise involving sports and fitness which could cause injury to them. You agree that your son/daughter is voluntarily participating in these activities and is assuming all risks of injury that might result. You hereby agree to waive any claims or rights that you might incur as a result of these activities. Green Mountain Gymnastics will make no evaluation or recommendation whether your son/daughter is physically fit for any physical activity. If your son/daughter has any physical condition that may impair his/her ability to engage in the activities, it is your responsibility to obtain a physician's statement describing any limitation to participate in this program. It is always advisable to consult a physician prior to undertaking any physical exercise program. I also release GMG of liability for anyone associated with this gymnast in the event of injury that may be incurred within GMG's premises.

Signature:___________________________________ Date:_________________

**What to wear: Shorts, sweat pants, t-shirts. Please do not wear clothing with buckles, snaps or zippers. No watches or jewelry allowed on floor.
**We are not responsible for lost or stolen merchandise.

Green Mountain Gymnastics
240 Pioneer Drive
Williston, VT 05495
802-652-2454
robin@GreenMountainGymnastics.com 		Directions from I-89 - exit 12
  • Go downhill to next Traffic light (intersection of Rte 2A and Marshall Ave).
  • Take a left onto Marshall Ave (Toys R Us is on the left).
  • Go through 4 sets of lights and take a left just past Federal Express onto Boyer Circle.
  • At the stop sign on Boyer Circle, bear left. Our Building is located on the left directly between Emery Worldwide and Commercial Tire.