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JGK ATHLETIC WAIVER
Student's Full Name (please only type name of student)
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First Name
Last Name
Parent or Guardian's Name (please type your name here mom, dad, guardian)
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First Name
Last Name
Age of Student
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
PHONE NUMBER (only give a number that is okay to call you on)
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Area Code
Phone Number
E-MAIL
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SCHOOL NAME
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CLASS(ES)
GYMNASTICS
HIP-HOP DANCE
CHEERNASTICS
PRESCHOOL GYMNASTICS
PRIVATE LESSON
ADULT HIP-HOP CARDIO
PERSONAL TRAINING (ADULTS)
SPIRITUAL MOVEMENT (ADULTS)
Please list any allergies, injuries, or medical conditions. Please also indicate if your child is ASD, ADD, OR ADHD.
*
Please list adults (18 or older) who have permission to pick up your child, other than parent/guardian. We can only release your child to those listed here.
*
I AM AWARE THAT PARTICIPATION IN THIS ACTIVITY MAY BE A POTENTIALLY DANGEROUS ACTIVITY INVOLVING MANY RISKS OF INJURY. I UNDERSTAND THAT THE DANGERS INCLUDE, BUT ARE NOT LIMITED TO; INJURY TO LIGAMENTS, MUSCLES, TENDONS, AND OTHER ASPECTS OF THE BODY, WHICH MAY INCLUDE NECK OR SPINAL INJURY. BECAUSE OF THE DANGERS OF THE ACTIVITY, I UNDERSTAND THE IMPORTANCE OF FOLLOWING THE COACH/INSTRUCTOR AND HIS OR HER INSTRUCTIONS REGARDING TECHNIQUES, TRAINING, AND OTHER RULES AND AGREE TO OBEY INSTRUCTIONS. IN CONSIDERATION FOR ALLOWING ME TO PARTICIPATE, I HEREBY ASSUME ALL THE RISKS ASSOCIATED WITH THE PHYSICAL ACTIVITY OF GYMNASTICS, DANCE, CHEER, SPIRITUAL MOVEMENT, PERSONAL TRAINING, AND ALL ACTIVITIES WITH JUMPIN' GYMKIDS PROGRAM, AND AGREE TO HOLD THE GYM AND ITS FACILITIES, EMPLOYEES AND AGENTS, HARMLESS FROM ANY AND ALL LIABILITY WHICH MAY ARISE IN CONNECTION WITH MY PARTICIPATION IN JUMPIN' GYMKIDS PROGRAMS AND ACTIVITIES. * I HAVE READ THE ABOVE WARNING AND RELEASE AND UNDERSTAND ITS TERMS.
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YES
I HEREBY GRANT PERMISSION TO JUMPIN' GYMKIDS (JGK) TO USE MY FILM/PHOTO IMAGE FOR DISPLAY ON THE JUMPIN' GYMKIDS WEBSITE AND/OR TO USE MY FILM/PHOTO IMAGE IN ANY EDUCATIONAL, INSTRUCTIONAL VIDEOS, YOUTUBE, CDROMS, SOCIAL MEDIA, OR PRINTED MATERIALS DEVELOPED AND DISTRIBUTED BY JUMPIN' GYMKIDS.
*
YES
NO
Electronic Signature
*
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