Forms Health Information Form "*" indicates required fields Name* First Last Birth of Date MM slash DD slash YYYY Age*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Emergency Phone*Email* Father* First Last Employer*Phone*Mother* First Last Employer*Phone*In case of emergency, and I cannot be reached please callName* First Last Relaton*Phone Number*Permission for emergency procedureDoctor*Phone Number*GymStars,LLC Waiver and Release Form Permission Liability Waiver and Indemnity Agreement: As a parent or guardian of a participant in activities offered by GymStars, LLC, I am fully aware of and appreciate the risks associated with participation in gymnastics and cheerleading activities and events. As conditions of the participation of the student described above ('my child') in any of the programs conducted by GymStars, LLC ('GS') including but not limited to tumbling, trampoline and gymnastics. I agree to the following: I waive any claim for bodily injury, personal injury, or property damage against GS, its directors, employees, and owners or lessors of the premises and any equipment used in connection with any programs of GS, arising out of our child's participation in any of the programs of GS whether on or off GS Gymnastics premises, or travel for the purpose of participating in any such programs or events. I understand that this weaver extends to injuries incurred by any member of my family, including my child identified above, myself, or any other family member. This agreement shall remain in effect as long as and whenever our child participates in any activity related to GS. If this agreement is not effective to waive liability on behalf of our child, ourselves, or any other family member, we further agree to indemnify GS for its liability including all costs, fees, and expenses incurred in connection with such liability. Photo Release: I authorize GymStars, LLC to use my or my child's photos, video, or audio for any advertising, decorative, or promotional purpose. Authorization of Medical Care: In case of illness or injury, I accept full responsibility for any and all associated medical costs and expenses. Acceptance of Rules and Policies: I have read and understand GS rules and policies and agree to abide by them through the course of my family's involvement with the program.or emergency procedureParticipant's Name*Printed Name of Parent or GuardianPhone NumberDate MM slash DD slash YYYY Signature*NameThis field is for validation purposes and should be left unchanged.
