STUDENT INFORMATION- nonmember
(This form may be printed out and brought with non members who are attending R. A. C. functions such as Sleepovers, Pizza Parties, or Birthday Parties. Please read the Rules and Policies and make sure your child understands them before the event.)
Student's Name: _____________________________________________________________________________
Address:____________________________________________________________________________________
Home Phone: ___________________ Birth Date: ________________ Age: _________
Mother's Name: ______________________________________________________________________________
Mother's Employer: __________________________________________ Work Phone: _____________________
Father's Name: ______________________________________________________________________________
Father's Employer: ___________________________________________ Work Phone: ____________________
Who to call if parents cannot be reached:
Name/ Relation: __________________________________________________ Phone: ( )________________
Name/ Relation: __________________________________________________ Phone: ( )________________
Doctor's Name: ___________________________________________________ Phone: ( )________________
Medical Insurance Co.: _________________________________________ Policy #: _______________________
Any intolerance to drugs or medication (please list): _________________________________________________
Any previous or current illness or injury the staff should be aware of :____________________________________
If so, are there any restrictions (please list): _______________________________________________________
WAIVER AND RELEASE FORM
With the understanding that R. A. C. Gymnastics Staff Members are not physicians or medical practitioners of any kind, I hereby release the staff to render temporary first aid to my child or children in the event of any injury or illness, and if deemed necessary, to call our doctor and to seek medical help, including transportation by a R. A. C. Gymnastics staff member or their representative, whether paid or volunteer, to any health care facility or hospital, or the calling of an ambulance for said child should the staff deem this necessary.
We, the staff of R. A. C. Gymnastics recognize our obligation to make our students and their parents aware of the risks and hazards associated with the sport of gymnastics, tumbling, cheerleading, weight lifting, and dance. Students may suffer injuries, possibly minor, serious, or catastrophic in nature. Gymnastics, Tumbling, Cheerleading, Weightlifting, and Dance can be dangerous and lead to injury! Parents should make their children aware of the possibility of injury and encourage their children to follow all the safety rules and the coaches instructions.
R. A. C. Gymnastics, its coaches and other staff members, will not accept responsibility for injuries sustained by any student during the course of gymnastics, tumbling, dance, or cheerleading instruction, or in open work outs, or in the course of any exhibition, competition, or clinic in which he or she may participate or while traveling to or from an event.
With the above in mind, and being fully aware of the risks and possibilities of injury involved, I consent to have my child participate in the programs offered by R. A. C. Gymnastics. I, my executors or other representatives, waive and release all rights and claims for damages that I or my child may have against R. A. C. Gymnastics and or its representatives whether paid or volunteer. I also affirm that I now have and will continue to provide proper hospitalization, health, and accident insurance coverage which I consider adequate for both my child's protection and my own protection.
I also understand that it is the parents' responsibility to warn the child about the dangers of gymnastics and injury. The parent should warn the child according to what the parent feels is appropriate. R. A. C. Gymnastics will only warn the child through Safety Messages and our teaching styles and progressions.
Parent or Guardian's Signature: ____________________________________________________ Date: ____________________
