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Wilson
School of Gymnastics and Dance ADULT Consent-Exculpatory Agreement Today’s Date
___________Your Name_______________________________________________ Street____________________________________________City____________________________ ST______
ZIP______ Your Telephone Number _______________________________________ Emergency
Contact ________________________ Telephone Number_______________________ As
an adult of legal age I acknowledge that I willfully choose to
participate/observe in the activity checked below which is sponsored by the
Wilson School of Gymnastics and Dance. As
with any physical activity there is an inherent risk of injury, possibly
catastrophic and assume full responsibility for injuries from existing
conditions/weakness. I, intending to be legally bound, do hereby, for myself, my
heirs, executors and administrators, waive and release any and all right and
claims for damages which may hereafter accrue to me against the Wilson School of
Gymnastics and Dance, it's directors, officers, employees, agents,
representatives, successors and/or assigns, for any and all damages which may be
suffered by me in connection with my participation in the Wilson School of
Gymnastics and Dance or which may arise out of traveling to, or participating
in, and returning from any activity within the program.
The School's representatives, in an emergency, have my permission and
consent, in the event that I am unable to give consent at the time, to utilize
at my expense, the most convenient emergency medical service or ambulance to
transport me to the nearest hospital. CIRCLE ONE:
Birthday Party
Toddler Class Field
Trip Adult Classes Other _____________ PLEASE CIRCLE existing medical problems: Epilepsy Allergies Diabetes
Asthma, Heart Disease If this is a
class for yourself, how did you find out about our program?
Circle One:
I GIVE PERMISSION
I DO NOT GIVE
PERMISSION to use my
picture on the Wilson School of Gymnastics and Dance web site. This would
possibly be a picture with a first name only.
No personal information is given on our website. SIGNATURE
________________________________________ DATE: __________________
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