Waiver and Release of Liability
2008-2009
DISCLAIMER: TRIAD GYMNASTICS IS NOT RESPONSIBLE FOR ANY INJURY (OR LOSS OF PROPERTY) TO ANY PERSON WHILE PRACTICING, TRAINING, TAKING CLASS, COMPETING, PARTICIPATING IN OPEN GYM, SPECIAL EVENTS, DEMONSTRATIONS, OR SHOWS OR IN ANY OTHER WAY INVOLVED IN GYMNASTICS, CHEERLEADING, PRESCHOOL, OR TEAMS AT TRIAD GYMANSTICS CLUB FOR ANY REASON WHATSOEVER, INCLUDING ORDINARY NEGLIGENCE ON THE PART OF TRIAD GYMNASTICS, ITS OWNERS, OFFICERS, AGENTS, OR EMPLOYEES.
In consideration of my participation, I hereby release and covenant not-to-sue Triad Gymnastics, L.C., the Triad officers, and any of their employees or agents, from any and all present and future claims resulting from ordinary negligence on the part of Triad Gymnastics, L.C. or other listed for property damage, personal injury, or wrongful death, arising as a result of my engaging in or receiving instruction in gymnastics, cheerleading, or any other activities incidental thereto, wherever, whenever, or however the same may occur. I hereby voluntarily waive any and all claims resulting from ordinary negligence, both present and future, that may be made by me, my family, estate, heirs, or assigns.
Further, I am aware that gymnastics and cheerleading are vigorous sporting activities involving height and rotation in an unique environment and as such they pose a risk of injury. I understand that gymnastics, cheerleading and related activities always involve certain risks, including but not limited to death, serious neck and spinal injuries resulting in complete or partial paralysis, brain damage, and serious injury to virtually all bones, joints, muscles, and internal organs, and that the mats, pits, and other safety equipment and apparatus provided for my protection, including the active participation of a coach or teacher who will spot or assist in the performance of certain skills, may be inadequate to prevent serious injury. The risk of harm may be limited by all of the safety equipment and trained coaches, but never eliminated. I understand that participation in gymnastics and related activities involves activities incidental to active participation in gymnastics, including moving from event to event, conditioning, stretching and other activities which may leave me vulnerable to the reckless actions of other participants who may not have complete control over their actions or who may not see other students in the gym. I am voluntarily participating in this activity with knowledge of the risks involved and hereby agree to accept any and all inherent risks of property damage, personal injury, or death.
I further agree to indemnify and hold harmless Triad Gymnastics and all other listed for any and all claims arising as a result of my engaging or receiving instruction in Triad Gymnastics, L.C. activities incidental thereto, whenever, wherever, or however the same may occur.
I understand this waiver is intended to be as broad and as inclusive as permitted by the laws of the state of Iowa and agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be within the state of Iowa.
I affirm that I am of legal age and am freely signing this agreement. I have read this form and fully understand that by signing this form, I am giving up legal rights and/or remedies which may be available to me for the ordinary negligence of Triad Gymnastics, L.C. or any person listed above.
Parent’s Signature____________________________________ Date__________________
Athlete’s Name______________________________________
Athlete’s Signature___________________________________ Date__________________
(if over 18 year of age.)
HEALTH HISTORY & MEDICAL RELEASE FORM
Triad Gymnastics
2008-2009
GYMNAST’S NAME:_________________________ D.O.B.___________
Date of last physical exam:________________ Blood type:______
Family Physician:______________________ Phone:_______________
Preferred Hospital:_______________________________________________
Health History (check all that apply)
____Frequent ear infections ____Heart defect / disease
____Convulsions ____Diabetes
____Bleeding/clotting disorders ____Hypertension
____Mononucleosis ____Psychiatric treatment
Date of last tetanus____________
Diseases (check all that apply)
____Chicken pox ____Measles ____Asthma
____German measles ____Mumps
Allergies (check all that apply)
____Hay Fever ____Ivy poisoning, etc.
____Insect stings ____Penicillin
____Other drugs (if yes, please specify:________________________)
Other medical conditions to which Traid staff should be alerted (specify)
Authorization for Treatment
Important- This must be completed for participation
This health history is correct so far as I know. I hereby give permission to the medical personnel selected by Triad Gymnastics staff to use appropriate procedures to aid my daughter,__________________ to prevent further injury and/ or death. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by Triad Gymnastics, L.C. to secure and administer treatment, including hospitalization, for my child as named above. The completed forms may be photocopied for trips out of facility.
Signature of parent or guardian:____________________________ Date:_____________
Triad Gymnastics, L.C.
D.O.B._____________ Home Phone:______________ Grade:______
Name & City of School:______________________ Dismissal Time:______
Home Address:_________________________________________________
Street City State Zip
Home e-mail address (for team news):______________________________
Other E-mail addresses:__________________________________________
Mother’s Employer:_________________________ Position:___________
Mother’s Work #:________________ Mother’s Cell #:_______________
Father’s Employer:______________________ Position:_______________
Father’s work #:_____________________ Father’s Cell #:_____________
__________________________________________________________________________________________________________________________
Emergency Contacts – to be used if above guardians cannot be reached:
_____________________________ _________________ ______________
Name of emergency contact relationship to athlete phone #
_____________________________ _________________ ______________
Name of emergency contact relationship to athlete phone #
Do we have your permission to distribute your name, address, phone number, and e-mail address to other team members? _____ yes _____no
Hospital and Physician Reference
Triad Gymnastics 2008-2009
GUARDIAN’S NAMES:_________________________________________
FULL ADDRESS:______________________________________________
STREET
CITY STATE ZIP CODE
WORK PHONE: Mom_______________ Dad________________
CELL PHONE: Mom________________ Dad________________
PREFERRED PHYSICIAN: Name_______________________
Phone_______________________
PREFERRED HOSPITAL:__________________________________
Do you carry family medical/hospital insurance? ____Yes ____No
If so, indicate: Carrier____________________________
Group or policy #__________________
ANY ADDITIONAL INFORMATION:_______________________________________________