Stoughton Gymnastics, LLC
201 W Main Street
Stoughton, WI 53589
Participation & Liability Waiver
Please list all children in your family on this single waver
Participant’s Name: __________________________________ Birthday: __________ Age: _____ Female __ Male __
Medical Insurance: Yes No___
Please list any medical conditions and/or relevant information that will assist us in teaching your child:
_______________________________________________________________________________________
Participant’s Name: __________________________________ Birthday:__________ Age: _____ Female __ Male __
Medical Insurance: Yes No___
Please list any medical conditions and/or relevant information that will assist us in teaching your child:
_______________________________________________________________________________________
Parent’s Name: ____________________________________________________________________________
Home Address: City & Zip: ___________________________________________________________________
Cell:__________________________________ Cell:____________________________________________
EMAIL Address(es):_________________________________________________________________________
Parent agrees to the Participation Liability Waiver and Consent, as described below
Parent Signature required: ______________________________________________ Date: ________________________
Participant Liability Waiver & Medical Treatment Consent:
I, the undersigned parent/guardian of the listed student, do hereby grant the authority to the staff of Stoughton Gymnastics to render judgment concerning medical assistance in the event of an accident, injury, or illness. I further authorize simple first aid, a medical or surgical diagnosis and treatment which may be deemed necessary. By the very nature of the activity, gymnastics, tumbling & trampoline and other sporting activities carry a risk of physical injury. NO matter how careful the student and coach are, no matter how many spotters are used, no matter what height is used or what landing surface exits, the risk cannot be eliminated. The risk of injury includes minor injuries such as bruises and more serious injuries such as broken bones, dislocations and muscle pulls. The risk also includes, and always includes catastrophic injuries such as permanent paralysis or event death from landings or falls on the back, neck or head. I hereby waive and hold harmless any and all Stoughton Gymnastics LLC. staff and other staff working in conjunction with Stoughton Gymnastics and any and all facilities and transportation vehicles Stoughton Gymnastics. deems necessary to use or teach from or be associated with-whether paid or volunteer-for any injuries, claims or damages in conjunction with Stoughton Gymnastics. I understand that as any athletic activity that involves motion or height, participation creates the possibility of injury. I have read and understand the risks involved in my child’s/ward’s participation at Stoughton Gymnastics. I hereby consent and wish to have my child/ward actively participate at Stoughton Gymnastics. Photo Release: I agree that photos of my child or me may be used for publicity for Stoughton Gymnastics (inside the gym, newspaper, website, Facebook, mailings, etc).
Stoughton Gymnastics, LLC
201 W Main Street
Stoughton, WI 53589
Participation & Liability Waiver
Please list all children in your family on this single waver
Participant’s Name: __________________________________ Birthday: __________ Age: _____ Female __ Male __
Medical Insurance: Yes No___
Please list any medical conditions and/or relevant information that will assist us in teaching your child:
_______________________________________________________________________________________
Participant’s Name: __________________________________ Birthday:__________ Age: _____ Female __ Male __
Medical Insurance: Yes No___
Please list any medical conditions and/or relevant information that will assist us in teaching your child:
_______________________________________________________________________________________
Parent’s Name: ____________________________________________________________________________
Home Address: City & Zip: ___________________________________________________________________
Cell:__________________________________ Cell:____________________________________________
EMAIL Address(es):_________________________________________________________________________
Parent agrees to the Participation Liability Waiver and Consent, as described below
Parent Signature required: ______________________________________________ Date: ________________________
Participant Liability Waiver & Medical Treatment Consent:
I, the undersigned parent/guardian of the listed student, do hereby grant the authority to the staff of Stoughton Gymnastics to render judgment concerning medical assistance in the event of an accident, injury, or illness. I further authorize simple first aid, a medical or surgical diagnosis and treatment which may be deemed necessary. By the very nature of the activity, gymnastics, tumbling & trampoline and other sporting activities carry a risk of physical injury. NO matter how careful the student and coach are, no matter how many spotters are used, no matter what height is used or what landing surface exits, the risk cannot be eliminated. The risk of injury includes minor injuries such as bruises and more serious injuries such as broken bones, dislocations and muscle pulls. The risk also includes, and always includes catastrophic injuries such as permanent paralysis or event death from landings or falls on the back, neck or head. I hereby waive and hold harmless any and all Stoughton Gymnastics LLC. staff and other staff working in conjunction with Stoughton Gymnastics and any and all facilities and transportation vehicles Stoughton Gymnastics. deems necessary to use or teach from or be associated with-whether paid or volunteer-for any injuries, claims or damages in conjunction with Stoughton Gymnastics. I understand that as any athletic activity that involves motion or height, participation creates the possibility of injury. I have read and understand the risks involved in my child’s/ward’s participation at Stoughton Gymnastics. I hereby consent and wish to have my child/ward actively participate at Stoughton Gymnastics. Photo Release: I agree that photos of my child or me may be used for publicity for Stoughton Gymnastics (inside the gym, newspaper, website, Facebook, mailings, etc).