Girl’s Team Registration Form
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Gymnast’s
Name |
Age |
DOB |
Sex |
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Address |
City |
State |
Zip |
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Home Phone
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Medical Conditions (i.e., allergies, previous injuries,
etc.) |
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Parent/Guardian Information: |
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Mother’s
Name |
Wk Phone |
Cell |
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Occupation |
Email |
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Father’s
Name |
Wk Phone |
Cell |
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Occupation |
Email
___________________________ |
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Emergency
Contact |
Phone |
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Family
Doctor |
Phone |
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Medical
Insurance Carrier Policy
No. |
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What
school(s) does your Gymnast attend: _____________________________________________________________ |
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Readiness to Compete
: I will only participate in those
activities for which I believe I am physically and psychologically prepared
to compete. Prior to participation in USA Gymnastics events, I will have
practiced my exercises, and will perform only those exercises which I have
accomplished to the degree of confidence necessary to assure I can perform
them by myself, and without injury. Medical Attention: I
hereby give my consent to Platinum Gymnastics Academy and to provide, through
a medical staff of its choice, customary medical/athletic training attention,
transportation and emergency medical services as warranted in the course of
my participation in any and all Platinum Gymnastics Academy activities. Waiver and Release: I
am fully aware of and appreciate the risks, including the risk of
catastrophic injury, paralysis, and even death, as well as other damages
and losses associated with participation in a gymnastics event. I further
agree that Platinum Gymnastics Academy, along with the coaches, employees,
agents, officers and directors of this organization, shall not be liable for
any losses or damages occurring as a result of my participation in any
training or event, except where such loss or damage is the result of the intentional
or reckless conduct of the organization or individuals identified above. |
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Signature
Parent/Guardian |
Date |
ATHLETE
MEDICAL HISTORY (To be completed by parent) -
Please
PRINT/TYPE
File for Coaches Use ONLY
Athlete’s Name:_________________________________USAG Region:____________USAG No.
Parent’s
Name:__________________________________Home
Phone (___)____-_____ Work
Family
Doctor’s Name:__________________________________Family
Doctor’s Phone (___)
Please
check () Please
explain any “Yes” answers to below questions in the space to the right of each
question:
Yes
No
1. Has had injuries
requiring medical attention.
Yes
No
2. Has had illness lasting
more than a week.
Yes
No
3. Is under physician’s care now
Yes
No
4. Takes medication now
Yes
No
5. Wears glasses (contact lenses: Yes
No
Yes
No
6. Has had a surgical operation
Yes
No
7. Has been in hospital (except tonsillectomy
Yes
No
8. Do you know of any reason why the
individual should not participate in gymnastics activities?
Yes
No
9. Has had complete poliomyelitis
immunization.
Yes
No
10.Has had a dental check-up in the past six months
11.
Most recent tetanus toxoid immunization date:
12.
List known allergies:
Parent’s
Signature:________________________________________
Date:
PHYSICIAN’S CERTIFICATE - To
be completed by physician -
PLEASE PRINT/TYPE
To
be completed by physician -
PLEASE PRINT OR TYPE
Name
of Athlete:_______________________________Age:_______Height:_______Weight:_______BP:
Significant
Illness or Injury:
EXAMINATION
SATISFACTORY UNSATISFACTORY NOT EXAMINED
Vision
Hearing
Respiratory
Cardiovascular
Liver,
Spleen, Kidney
Hernia,
Genitalia
Musculoskeletal
Skin
Neurological
Lab
Tests-Urinalysis
Other
I certify that I have examined this athlete and find
her physically able to compete in supervised gymnastics.
Physician’s
Address:
City:
Date:
__________________ Signed:________________________________________
M.D.