Waiver

* (denotes required field)

Today's Date *

First & Last Name *

Age/ Birthdate & Grade *

Parents Name *

Street Address *

City *

State & Zip *

Home Phone # *

Allergies & Medical Conditions *

Legal/ Custody Issues? *

Contact Information

Mom's Name *

* At least email one email address is required

Email *

Occupation *

Dad's Name *

Occupation *

Email *

Cell Phone / Work Phone *

(Some to contact if parents can't be reached)

Emergency Information *

First & Last Name *

Cell Phone#

Referral Source: (Please name) Location Referral/Friend _________ Internet/Google coachrandygarcia.com Website C.G.Birthday AT&T Yellow Pages Field Trip Mom’s Club/Homeschool Change Gyms Other (Please list)_____ REG. FEE—DATE PAID _____

I have read and understand the following *

Secondary Excess Coverage Creative Gymnastics group insurance is “SECONDARY EXCESS COVERAGE” over any valid collectable coverage provided by the parents’ separate or employees’ dependent group insurance. This secondary excess accident medical insurance coverage has a $100 deductible which Creative Gymnastics DOES NOT PAY in the event of an accident. Permission Slip I give permission for my child to attend Camp. I confirm that my child is in good health and that he/she has had a physical exam within the last six months. In the event of an emergency I authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute gen- eral hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. This authorization is given pursuant to the provisions of section 25.8 of the Civil Code of California. Filling this form is your electronic signature*. *Signature of Father, Mother, or Legal Guardian Please Initial: _______ Child’s Safety: I understand that I am responsible for my child’s behavior and safety while on the premises of Camp including parking lots, restrooms, waiting areas, etc. ________ I understand that no credit is ever given for missed camp days. ________ I understand that camp fees are NON-REFUNDABLE without a seven (7) day WRITTEN notice. ________ I understand that special activity fees (including Sleepovers, Parents’ Night Out, Jr. Open Gym, etc) are NON-REFUNDABLE without 24 hours notice. _____Photos will be taken during clamp for marketing purposes, etc. Release of Liability Waiver Name of participant(s) below I (we) despite all reasonable precautions implemented for safety, am (are) fully aware of and appreciate the risks , including the risk of catastrophic injury, as well as other damages and losses associated with participation in the programs or activities. I (we) knowingly and willingly assume all such risks. Conse- quently, I (we) hereby for myself, heirs, executors and the administers, do waive and release any and all rights and claims for damages against the owner, operators, coaches and other members of Creative Gymnastics Camp from personal injury or accident of any sort or nature suffered by me (us), the undersigned, by reason of participation or membership in classes, lessons, or any programs or activities of Creative Gymnastics Camp.

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