Student Information:

Child’s Name _________________________________________ Age ______ DOB ____________ Sex _____

Child’s Name _________________________________________ Age ______ DOB ____________ Sex _____

 

Address _____________________________________________ City ________________________ State ______

 

Home Phone ___________________ Apt. # _________ Zip_____________

 

Medical Conditions, if any __________________________________________________________________________

 

Parent/Guardian Information:

Mother’s Name _______________________________ Cell __________________ Wk Phone________________

Occupation ____________________________________ Email _______________________________________

 

Father’s Name ________________________________ Cell __________________ Wk Phone________________

Occupation ____________________________________ Email ______________________________________

 

Emergency Contact _________________________________________ Phone ___________________________

Family Doctor ______________________________________________ Phone ___________________________

 

How did you hear about us? _________________________________________________________________________

 

Medical Release Form

• Eligibility: I agree to comply with the rules and policies of Platinum Gymnastics Academy.

• Participation: I consent to have my child/children participate in the programs Platinum Gymnastics Academy offers. I, my executors, or other

representatives, forever waive and release all rights and claims for damages that I or my child may have against Platinum 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.

• Medical Attention: I fully understand that Platinum Gymnastics staff members are not physicians or medical practitioners of any kind. With the

above in mind, I hereby release Platinum Gymnastics staff to render first aid to my child or children in the event of any injury or illness, and if

deemed necessary by the Platinum staff, to provide through a medical staff of it’s choice, customary medical/athletic training attention,

transportation by a Platinum Gymnastics staff member or its representatives, whether paid or volunteer, or the calling of an ambulance should

the Platinum staff deem this necessary.

• Waiver: I am aware that I should make my child or children aware of the possibility of injury and will encourage my children to follow all the safety

rules and the coach’s instructions. 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 gymnastics activities and events. I further understand that it is the parent’s

responsibility to warn their children about the dangers of gymnastics and injury. Platinum Gymnastics Academy, its coaches, and other staff

members, will not accept responsibilities for injuries sustained by any student during the course of gymnastics, trampoline, tumbling, cheerleading,

open gym, or other programs in the case of any exhibition, competition, or clinic in which my children may participate while traveling to or from the

event. I also agree that Platinum Gymnastics Academy, its coaches and other staff members, shall not be liable for any losses or damages

occurring as a result of my children’s participation in the event. Platinum Gymnastics Academy will only warn the children through “Safety

Messages” and our teaching style and progression.

 

 

I do hereby verify that I have read and understand and accept each of the above policies and conditions

shown by my signature below.

Signature Parent/Guardian ____________________________________Date ___________________________

 

 

 

 

 

Platinum Gymnastics Academy

Lunch-tastics

1410 Royston Ln. Round Rock, TX 78664

Ph: 251-2776 Fax: 251-2782

go2platinum.org