Child's name:				DOB:		Age:	Male   Female
Street:					City:		ZIP:
Parents/Custodial parent or legal guardians:
Phone Numbers		Home		Work		Cell
Parent
Spouse/Partner
Email address: (GMG needs this information to keep you informed of class changes or upcoming events)
Person responsible for the payment on this account:
Street:					City:		ZIP:
Home phone:		Work phone:		Cell phone:		Email:
Doctor's Name:					Doctor's phone #:
In case of emergency, please call (other than parent):				Phone		Relationship
Name:
Name:
PLEASE INFORM US OF ANY MEDICAL CONDITIONS OR ALLERGIES

Green Mountain Gymnastics, Inc.
240 Pioneer Drive, Williston, VT 05495
Waiver/Release Form

No child will be allowed to participate in any programs unless this form is completely filled out, signed and filed with GMG prior to commencing participation **READ THE FOLLOWING CAREFULLY AND SIGN BELOW. NOTE; BOTH PARENTS/CUSTODIAL PARENT AND LEGAL GUARDIAN MUST SIGN ON BEHALF OF EACH PARTICIPATING CHILD! **

Agreement In consideration of my child's participation in Green Mountain Gymnastics Inc. (further referred to as GMG) events and activities, I hereby agree to be bound by each of the following terms and conditions: Eligibility: I agree to comply with the rules of GMG. Readiness to Participate: I will only participate in those GMG classes, events, competitions and activities for which I believe I am physically and psychologically prepared. Prior to participation, I will have practiced by exercise and will perform only those exercises, which I have accomplished to the degree of confidence necessary to assure I can perform them by myself and without injury. Medical Attention: I hereby give my consent to GMG and/or host Organization to provide, through a medical staff of choice, customary medical/athletic training attention, transportation and emergency medical services as warranted in the course of my participation in the event, except where such loss or damage is the result of the intentional or reckless conduct of one of the organizations or individuals identified above. Waiver and Release: I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis and even death, as well as other damages and losses associated with participation in gymnastics activities and events. 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. I further agree that GMG and the sponsor of any GMG event, along with the employees, agents, officers and directors of these organizations, shall not be liable for any losses or damages occurring as a result of my/our child's participation in any GMG event or activity, except where such loss or damage is the result of intentional or reckless conduct on one of the individual (s) /organization (s) mentioned above. INFORMATION: Primary Medical Insurance: I am covered by a primary health/medical/accident insurance through: ______________________________________________________________________________ For any athlete who is not yet 18 years old: As the legal parents, guardian or custodial parents of this athlete, I hereby verify by my signature below that I fully understand and accept each of the above conditions for permitting my child to participate in classes, events, competitions and activities conducted by GMG. This waiver/ Release form shall remain in effect for as long as ______________________________ (name of Child) participates in any GMG activity until such time of written notice rescinding this waiver/ release is received by GMG. Name of Child: _____________________________________________ Printed name of Both Parents/Legal Guardian(s), Custodial Parent(s): _____________________________________     _____________________________________ Signatures of Both Parents/Legal Guardian(s), Custodial Parent(s): _____________________________________     _____________________________________ Dated: ____/____/____