Acros Gymnastics & Dance

ACROS GYMNASTICS, INC.

  

Mother’s First  Name ­­­­­­­________________________ MI _____  Last Name _______________________________  

Fathers First Name                                                          MI                 Last Name                                                                           

Address _________________________________  City ________________________________________

State _______________________                Zip ________________________ Date ________________________

Home Phone _____________________________  Cell Phone ___________________________________

Mom’s Work  Number _______________________________ Dad‘s Work Number ______________________________________

Emergency Contact __________________________________Phone Number ___________________________________________

Email _________________________________Primary Insurance/Policy Number ________________________________________

                Student’s Name                                    Birthday                                 Sex          Medical Conditions/Medications

1.  _______________________________   ______/______/______   M/Fe      __________________________________________

2.  _______________________________   ______/______/______   M/Fe      __________________________________________

3.  _______________________________   ______/______/______   M/Fe      __________________________________________

4.  _______________________________   ______/______/______   M/Fe      __________________________________________

 

How did you hear about ACROS?  _________________________Which radio station do you listen to?  _______________________

 

 

PARENTAL CONSENT AND HOLD HARMLESS

 

                The undersigned parent or guardian of ____________________________ (“STUDENT”) does hereby certify that no other person has legal custody of the STUDENT; and that the undersigned hereby expressly agrees and consents to participation by the STUDENT in all programs and activities conducted upon or taking place within the premises of ACROS Gymnastics, Inc. (“ACROS”) in Vanderburgh ,County, Indiana.  The undersigned agrees and acknowledges that there are risks of injury to the STUDENT, including a potential for permanent disability or death, resulting from such participation or from the use by the STUDENT or other of equipment involved in the activity, and with such knowledge freely assumes all such risks to the STUDENT, known or unknown, and assumes full responsibility therefore.

                The undersigned has read and understands the rules, including all safety-related rules, with respect to the participation by the STUDENT in such activities and agrees that the STUDENT will fully comply therewith in all respects.

                In consideration of permitting the STUDENT’S  participation in such activities, and full understanding the risks involved, the undersigned agrees to and does hereby release, indemnify and hold the ACROS and it’s officers, directors, shareholders, managers, employees, agents and volunteers harmless, without limit as to time or amount, from and against any and all claims, demands, causes of actions and damages of any kind whatsoever (plus ACROS’ attorney’s fees and all costs of litigation incurred by it), including, but not limited to, any of the same growing out of negligence on the part of the ACROS, past present or future, which may now or hereafter be asser5ed by reason of any loss, injury or damage to the person or property of the STUDENT, or of the undersigned, within or anywhere about the premises of the ACROS, it being the intention of the undersigned that this instrument of release and indemnity shall be a complete bar to all such claims, demands or causes of actions, regardless of when arising or by whom asserted.  The undersigned agrees that the provisions hereof shall be contractual and not mere recitals, and that this release and indemnity agreement shall be binding upon the heirs, personal representatives, beneficiaries, legal representatives, and assigns of the undersigned.

                The undersigned represents that the STUDENT is in good health, but authorizes emergency medical aid where necessary, including x-rays and other diagnostic tools.

 

Dated this _______day of ________, 20__.

Signature_______________________________________ Print Name ___________________________________________

Relationship to Student ______________________________________________________

Welch Family Enterprises, LLC
333-C North Plaza East Blvd.
Evansville, IN 47715
812-476-5999