Medical Release Form
Students Name__________________________________________
Students Phone #________________________________________
Address________________________________________________
School_________________________________________________
Grade__________________________________________________
Age-DOB_______________________________________________
Parents Name___________________________________________
Home phone#___________________________________________
Work phone#____________________________________________
Medical problems________________________________________
Current medications______________________________________
Allergies________________________________________________
In case of Emergency contact______________________________
Name___________________________________________________
Phone numbers__________________________________________
Relationship_____________________________________________
I
hereby grant permission for the persons enrolled to participate
at Capital Gymnastics National Training Center. I am aware and
understand the risks involved in the sport, and I release Sergio
R. Galvez/Capital Gymnastics and it's employees from any and
all liability which might be incurred during the conduct of this
activity.
In an Emergency, I hereby grant permission to their employees,
to have authority, at my expense, in the event I cannot be
readily reached, to utilize the most convenient volunteer rescue
squad vehicle or ambulance to transport my son or daughter to
the hospital and if necessary, I authorize medical treatment. I
hereby verify that the student has passed a medical examination
within the last twelve (12) months and is capable of participating
in the sport of gymnastics and tumbling.
Signed_________________________________________________
Name__________________________Date____________________