All who participate in any party must sign a waiver!

Birthday party waiver

Child's Name

First Name

Last Name

Date of Party

MM

DD

YYYY

Time of Party

Hour

Minute

Second

Gender

Female

Male

Child's Age

Child's Birth Date

MM

DD

YYYY

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone

(###)

###

####

Emergency Phone

During this activity.

(###)

###

####

Email Address

ASSUMPTION OF RISK, WAIVER OF LIABILITY AND MEDICAL AUTHORIZATION

As legal guardian of the child listed above, hereafter, child(ren) I recognize what potentially severe injuries, including permanent paralysis or death can occur in sports or activities involving height or motion, including but not limited to gymnastics, tumbling, trampoline, rock climbing, dance, yoga, cheerleading, parties, and special events. Being fully aware of these dangers, I voluntarily consent and ACCEPT ALL RISKS associated with the participation of the aforementioned person(s) participating, as well as myself, in any and all Dominique Moceanu Gymnastics Center programs and activities including if I as a parent or guardian must enter the gym for any reason. Also, if your child requires an inhaler, I understand I am required to stay with him/her or get a doctor’s release. If any participants are injured (cast, crutches, recent stitches, etc.) they may participate by observation only, unless we have a doctor’s release. In consideration for allowing me and my child(ren) to use these facilities, I, on my behalf of my child(ren) and our respective heirs, administrators, executors and successors, hereby COVENANT NOT TO SUE and FOREVER RELEASE, its officers, directors, shareholders, employees or agents from all liability for any and all damages or injuries suffered by my child(ren) while under the instruction, supervision, or control of Dominique Moceanu Gymnastics Center, including, without limitation, those damages or injuries resulting from acts of negligence on the part of its officers, directors, shareholders, employees, or agents. In the event of an emergency, I would like my above mentioned child(ren) to be taken to a hospital for medical treatment and I hold Dominique Moceanu Gymnastics Center, and its representatives harmless in their execution of this action. Additionally, I hereby agree to individually provide for all possible future medical expenses which may be incurred by me or my child as a result of any injury sustained while participating at or for Dominique Moceanu Gymnastics Center. By attending this birthday party listed above, I am granting your permission for my child to be filmed, videotaped, audiotaped or photographed by any means and are granting full use of your likeness, voice, and words without compensation. I have read and understood this ASSUMPTION OF RISK, WAIVER OF LIABILITY and MEDICAL AUTHORIZATION. I VOLUNTARILY affix my name in agreement. Please Type Your Name As Proof Of Signature and Acceptance of the Terms of this Release Form:

Today's Date

MM

DD

YYYY