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Wilson School of Gymnastics and Dance Parent or Legal Guardian's Consent-Exculpatory Agreement This Agreement is Valid From Date Signed to August 31, 2009
Today’s Date___________________ Student's Name ___________________________________________
Parent/Guardian's Name _________________________Home Phone
#_____________________
City____________________________________State_________ZIP_________________
Student's Age_________ Student’s Birth date_____________ Email (Optional)___________________________
I, as parent or legal guardian of the above student hereby grant permission for him/her to participate in the specific program set forth above, conducted by the Wilson School of Gymnastics and Dance, and in consideration of my child being permitted to enroll and participate in said program with the Wilson School of Gymnastics and Dance, 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 my child or 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 my minor child or by me in connection with my child's enrollment and 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 I cannot readily be reached, to utilize at my expense, the most convenient emergency medical service or ambulance to transport my child to the nearest hospital.
As with any physical activity there is an inherent risk of injury, possibly catastrophic, while participating in cheerleading, gymnastics or dance. Children who enroll in the program should be in good health.
CHECK ONE:
_____My child has been examined by a physician to determine whether he/she is fit to participate in dance/gymnastics/cheerleading.
_____My child has not been examined by a physician before entering the program and I assume full responsibility for injuries from existing conditions/weakness.
PLEASE CIRCLE EXISTING MEDICAL PROBLEMS: Epilepsy Allergies Diabetes Asthma Scoliosis. Other, please explain:
* Children who are absent due to extended illness or injury must have written permission from their physician, and/or parent to return to the program.
How did you hear about Wilson School of Gymnastics? (Circle One)
Friends Yellow Pages Internet Search Website Economizer Coupon
Book Road Sign Newspaper
________I give permission to use my child’s picture on the Wilson School of Gymnastics and Dance web site. This would be a picture with a first name only. No personal information is given on our website.
________I do not give permission to use my child’s picture on the Wilson School of Gymnastics and Dance web site.
Parent or Legal Guardian’s Signature________________________________________________________ Date_______________________ |