10.0 ACADEMY

181 Great Rd. Stow MA 01775

978/8978184 fax 978/897-8198

It’s A Gymnastics Party!

Each child must bring this waiver/release form signed by their parent or guardian.

Forms need to be presented to the instructor before entering the gym.

WHAT TO WEAR? Boys and girls must be dressed for gymnastics activities.

NO jeans, dresses, tights or clothing with exposed zippers, snaps or buttons allowed.

This is a safety precaution.


Child's Name _________________________________________________

Boy / Girl                Age _____                              D.O.B _____/_____/____


Address ____________________________________________________

City ___________________ Zip_________ Home Phone _______________

Emergency Phone ___________________ Contact person ______________

Please list any medical information we should be aware of food allergies:

______________________________________________________________

Has any one in the family ever attended 10.0 ACADEMY before? Yes/No


AUTHORIZATION OF PARTICIPATION:

I, as parent or legal guardian of above named, hereby give permission to said son/daughter to participate at 10.0 ACADEMY. I understand that gymnastics is a sport that involves height and rotation of the body, therefore there are inherent risks involved. I agree to release 10.0 ACADEMY, and all instructors and assistants from any liability from harm or injury arising from participation in these activities. I hereby testify as to my child's sound health of mind and body and I authorize 10.0 ACADEMY.

 to seek medical treatment at the nearest Medical Facility in case of emergency.


________________________________________________________
Signature of Parent or Legal Guardian Date

Printed Name:________________________________________________