Allbrook Gymnastic Club (A California Corporation) Student Information Sheet And Medical Release printable pdf download

FALLBROOK GYMNASTIC CLUB

(A California Corporation)

STUDENT INFORMATION SHEET AND MEDICAL RELEASE

FIRST NAM E

LAST NAM E

DATE OF BIRTH

1__________________

___________________________________ ______/______/______

2 __________________

___________________________________ ______/______/______

3 __________________

___________________________________ ______/______/______

Students Address_________________________________________________________________________

City ___________________________________________________ Zip____________________________

Home Phone(_____)______-_________

W ork Phone( _____)______-____________ Email:_________________________

M om’s Cell(_____)______-_________

Dad’s Cell(_____)______-_________

Pager(_____)______-_________

Other than parent Emergency Phone(____)_____-_________

Emergency Contact ______________________

Family Doctor_______________________

HOW DID YOU FIND US?

__ Friend_______________ __ Sign __ Yellow Page F A P __ Newspaper __ Flier __ Other____________

MEDICAL RELEASE & WAVER

I, the parent/guardian of ____________________________________know that participation in any sport is a potentially hazardous activity.

I realize that he/she should not participate unless he/she is medically able and properly trained. I assume all risks associated with his/her

participation. Having read this waiver and knowing these facts and in consideration of your accepting my child’s application to participate,

I waive and release the Fallbrook Gymnastic Club, all sponsors, affiliated Clubs, event organizers, and officers and members thereof from

all claims or liabilities of any kind arising out of his/her participation. Should emergency medical treatment be necessary during this

instruction, I hereby grant consent to apply the following medical treatment to myself ( or my child in my absence ): any examination,

anesthetic, medical or surgical diagnosis and/or special supervision of duly licensed physician or surgeon. This consent is given in advance

of any specific diagnosis.

__________________________________

________________________ _____\_____\_____

Printed Parent/Guardian's Name

Signature Parent/Guardian's

Date

Does your child have any medical problems that in any way will effect your child's participation in the sport of GYMNASTICS ? (include

Allergies, learning disabilities, & Physical Handicaps). If yes Please explain. This question is only asked to aid the instructor in dealing

with your child and of course safety of your child. Please state if you have a preference to which local facility to bring your child in case

of medical emergency. (ie. Fallbrook Hospital, Camp Pendleton).

______________________________________________________________________________

Date Filed ________/________/_________

For Office Use Only

Allbrook Gymnastic Club (A California Corporation) Student Information Sheet And Medical Release

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