Parent-and-Me-Waiver

Child’s Name_____________________________________________Age_________Birthday____________________

Sibling__________________________________________________Age_________Birthday____________________

Does the child(ren) have any limitations/disabilities/injuries? _____________________________________________

______________________________________________________________________________________________

Parent’s Name_____________________________________E-mail ________________________________________

Home Phone__________________________Work________________________Cell___________________________

Address _______________________________________________________________________________________

City__________________________________________________________State_______________Zip___________

Emergency Contact: (If parent not available or not staying with child) __________________________________________

Relationship___________________________________________________________Phone____________________

Insurance Carrier_____________________________Insured’s Name_____________________Policy______________

Referred By: ____________________________________________________________________________________

Release and Waiver of Liability for Participant and Parent

Participant and/or parent have elected to take part in certain recreational activities. In consideration for and as a condition of such participation, participant/parent agrees to assume all risk involved with participation and agrees to hold Pacific Coast Gymnastics Center, and its instructors and employees, harmless from all suits, claims, or demands of every kind and character arising out of or in connection with the undersigned as a participant in said recreational program.

Participants further releases Pacific Coast Gymnastics Center (PCGC), its instructors and employees, from all suits claims or demands of every kind and character which participant or participant’s successors or assigns shall or may have arising out of or by reason of or in connection with the course of instruction and activities contemplated in the program. It is understood that participation in this activity could result in serious injury and/or death. It is declared that said participant(s) is physically fit to participate in the program and is in good physical condition.

I understand my insurance company is responsible for my child(ren) and myself if applicable while participating in activities at PCGC.

Parent Signature_______________________________________________ Date___________________________

In the event of an emergency such as illness or injury, the parents of the student will be called first. If parents are not available, then the emergency contact will be called. If neither is available the child will be taken to the nearest emergency room.

We authorize Pacific Coast Gymnastics Center officials or staff to arrange for such transportation and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provision of the medical practice act, whether such diagnosis or treatment is rendered at the physician’s office or at the hospital. This authorization is given pursuant to provisions of Section 25.8 of the Civil Code of California.

Liability Waiver for Special Events and Parent & Me Classes

8981 La Linia, Suite A

Atascadero, CA 93422

Phone: 805-466-1483

Fax: 805-466-1490

www.pcgymnastics.com