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POMEROY GYMNASTICS, INC.
BIRTHDAY PARTY RELEASE FORM
Students Name__________________________________ Sex______ Age______ Date of Birth ______/______/______
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