Wilson School of Gymnastics and Dance - Multiple Children Form
Parent or Legal Guardian's Consent-Exculpatory Agreement
This Agreement is Valid From Date Signed to August 31, 2009

Student's Name ________________________________________________________ Age _______ Birth Date _______________
PLEASE CIRCLE EXISTING MEDICAL PROBLEMS: Epilepsy Allergies Diabetes Asthma Scoliosis.  Other, please explain:

Student’s Name ________________________________________________________  Age _______  Birth Date _______________
PLEASE CIRCLE EXISTING MEDICAL PROBLEMS: Epilepsy Allergies Diabetes Asthma Scoliosis.  Other, please explain:

Student’s Name ________________________________________________________  Age _______  Birth Date _______________
PLEASE CIRCLE EXISTING MEDICAL PROBLEMS: Epilepsy Allergies Diabetes Asthma Scoliosis.  Other, please explain:

Parent/Guardian's Name ______________________________Home Phone #______________________ Cell __________________

Street____________________________________________________________ Email (Optional)___________________________

City__________________________________________________State________________ZIP________________________

    I, as parent or legal guardian of the above students 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 children 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 children 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 children or by me in connection with my children’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 children 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 children have been examined by a physician to determine whether he/she is fit to participate in dance/gymnastics/cheerleading.

_____My children have not been examined by a physician before entering the program and I assume full responsibility for injuries from existing conditions/weakness.  

 * 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   Economiser Coupon Book   Road Sign   Newspaper   TV   Other ____________

 ________I give permission to use my children’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 children’s picture on the Wilson School of Gymnastics and Dance web site.

 Parent or Legal Guardian’s Signature_____________________________________________ Date_______________________