Release Form | EmethGym

What are you here for?*

Classes

Birthday Party

Event (Open Gym, Clinic, Parent's Night Out)

Other

Who is the primary guardian/contact?*

Mother

Father

Other

Primary Guardian/contact name*

First Last

Mother's Name

First Last

Father's Name

First Last

How many children?

Child's Name*

First Last

Child's Date of Birth*

Boy or Girl?*

Girl

Boy

Second Child's Name*

First Last

Second Child's Date of Birth*

Second Child: Boy or Girl?*

Girl

Boy

Third Child's Name*

First Last

Third Child's Date of Birth*

Third Child: Boy or Girl?*

Girl

Boy

Primary Contact Email*

Enter Email Confirm Email

We send important enrollment, billing and updates to this address! We keep your information safe!

May we send you email news & announcements?

Yes!

Primary Phone*

Primary Phone Description*

Mother Cell

Father Cell

Other

Secondary Phone*

Secondary Phone Description*

Mother Cell

Father Cell

Other

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact

Emergency Contact Name*

First Last

For if you are unreachable in an emergency

Emergency Contact's Phone*

How is emergency contact related to student(s)?**

Specific information we should know about your child(ren):

Any special conditions or severe allergies Emeth staff should be aware of?

Terms & Liability Release*

RISK. In completing this form, I understand that even though the policies, teaching format, and progressions in the programs offered by Emeth Gymnastics are developed with a mindset of safety, there is still the risk of minor or serious injury, including death, for all participants (including parents participating with students), even when all safety precautions have been taken.
I consent to have the student(s) named above participate in the programs offered by Emeth Gymnastics.

SUPERVISION. I understand that Emeth is not equipped or staffed to supervise children before or after designated class times. I will not hold Emeth responsible for any damages or injuries that might occur if my children remain at Emeth outside of designated class times without supervision.

VIRUS RISK. I understand the although Emeth Gymnastics follows strict protocol regarding sanitation and cleanliness, due to the contagious nature of certain bacteria and viruses, including but not limited to the virus causing COVID-19, I voluntarily assume the risk that my children and/or I may be exposed to or infected by such bacteria or viruses while attending Emeth Gymnastics. I understand that such exposure or infection could result in illness, permanent disability, or death.

PHOTO RELEASE. I understand and consent to the use of photos and/or videos of student(s) named above by Emeth Gymnastics for recognition of her/his accomplishment and for marketing purposes.

RULES & RELEASE FROM CLAIMS FOR DAMAGES. I agree to respect and comply with all the policies and rules of the Emeth Gymnastics program. I, my executors, and/or other representatives hereby waive and release all rights and claims for damages that I, my children, student(s) listed above, or other family members may have against Emeth Gymnastics and its representatives, whether paid or volunteer.

INSURANCE COVERAGE. I affirm that I have and will continue to provide proper hospitalization, health, and accident insurance coverage which I consider adequate for the protection of both myself and student(s) named above.

PERMISSION FOR EMERGENCY MEDICAL TREATMENT. I hereby give permission for the emergency medical treatment of student(s) named above.

CERTIFICATION. My signature below certifies that I am a legal guardian of the named child(ren) on this form. I agree to all the terms stated above and am releasing Emeth Gymnastics from liability.

I agree to the above release of liability

Type Your Name Here:*

First Last

Parent / Guardian Signature*

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Referral Source

Name

This field is for validation purposes and should be left unchanged.

EmethGym Release Form

Emergency Contact

Specific information we should know about your child(ren):

Training Leaders With True Confidence.

Start your child strong.

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