Camp Liability Release & Emergency Form
GENERAL INFORMATION

Birth date                                                        

City                                                     

Cell Phone

Work Phone

Cell Phone
           
Work Phone

Home Phone

Emergency Contact Phone



Phone

Phone

Phone


State


Zip


Child’s Name                                                                                                                                                         

Address                                                                                                            

Parent’s Name                                                                                              

                                                                                                                      

Parent’s Name                                                                                              
            
                                                                                                                     

Parent Email                                                                                                 

Alternative Emergency Contact                                                                    

Additional adults with permission to pick up above named child from camp:

(1)                                                                                                                 

(2)                                                                                                                  

(3)                                                                                                                  

Is your child currently taking medications?                                         Is your child presently being treated for an injury or illness?   
Does your child have any allergies (medicine/food/etc)?   
If you answered yes to any of the above, please explain.
Does your child have any physical condition or illness which would prevent him/her from participating in normal, rigorous activity?   
                   If yes, explain.
Does your child suffer from any of the following (select all that apply and explain below):

Other Explain

I give permission for photos of my child to be posted on Gymnastic World website, face book page, advertisements, etc.

If at any time information changes, please inform Gymnastic World office staff of updates.

LIABILITY RELEASE & CONSENT

Gymnastic World of Fort Myers, its coaches and other staff members, do not accept and will not be held responsible for injuries sustained by any
member, student or visitor during the course of gymnastics, tumbling, dance or other activities during camps or in the course of any exhibition,
competition or clinic in which she/he may participate or while traveling to or from any event.

With the above in mind and being fully aware of the risks and possibility of injury involved, I                                                                                     
as parent/legal guardian of the above named child(ren), consent to have my child(ren) participate in the programs offered by Gymnastic World of
Fort Myers.  I further agree that I, my executors or other representatives, hereby waive, hold harmless and fully release all rights and claims for
damages that I or my child(ren) may have against Gymnastic World of Fort Myers, and/or its representatives whether paid or volunteer.

By the signing of this document, by means of typing my name below, I agree that the information above is accurate and I agree to the Liabilty
Release & Consent stated above.


Signature                                                                                                                                                                    
                                                       
Print Name                                                                                                              
  Parent or Legal Guardian
Date
Relation to child
Please fill out the form in its entirety, as most fields are required. If you prefer to print a copy and bring in for your child’s first day of camp,
please download a copy of the form HERE.
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