JGK ATHLETIC WAIVER

Student's Full Name (please only type name of student) *

First Name Last Name

Parent or Guardian's Name (please type your name here mom, dad, guardian) *

First Name Last Name

Age of Student *

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

PHONE NUMBER (only give a number that is okay to call you on)

- Area Code Phone Number

E-MAIL *

SCHOOL NAME *

CLASS(ES)

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. *

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 *