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BIRTHDAY PARTY RELEASE FORM

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POMEROY GYMNASTICS, INC.

BIRTHDAY PARTY RELEASE FORM

 

Students Name__________________________________ Sex______ Age______ Date of Birth ______/______/______

 Address____________________________________________________________________________________________
                                Street                                                                     City             State             Zip

Mothers Name___________________________________ Fathers Name_______________________________________

 Home Phone # ______-_____-_____       Work Phone # _____-_____-_____        Cell Phone # _____-_____-_____

 How did you hear about Pomeroy Gymnastics? _________________________________________________________

Emergency Phone Number and Contact ______-______-______    __________________________________________

 Are there any medical conditions to which we should be alerted? _________________________________________

 ___________________________________________________________________________________________________

 

ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY

 

As legal guardian of ______________________________, I hereby consent to aforementioned person participating in Pomeroy Gymnastics, Inc.’s programs.  I recognize the potential for injuries which may occur in any activity involving height or motion.  I understand that it is the express intent of Pomeroy Gymnastics, Inc. to provide for the safety and protection of my child and, in consideration for allowing my child to use these facilities, I hereby forever release Pomeroy Gymnastics, Inc. or its employees.  As legal guardian of the aforementioned person, I hereby agree to individually provide for the possible further medical expenses which may be incurred by my child as a result of any injury sustained while training at, or performing for  Pomeroy Gymnastics, Inc.

This acknowledgment of risk and waiver of liability, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.

 

 ____________________________________________                              ________________________________

            Parent or Legal Guardian’s Signature                                                             Date

 

 

 

Ċ
Jeff Pomeroy,
Feb 1, 2011, 7:42 AM
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