The Gymnastics Training Center of Rochester, Inc.                  2051 Fairport Nine Mile Point Road, Penfield, NY 14526               585-388-8686; FAX 585-388-0018;               email: gtc@frontiernet.net

                                           WAIVER/RELEASE FORM   (PLEASE PRINT CLEARLY)

   EVENT____________________________________________________________________________________________________

  CHILD’S NAME     __________________________________________DATE OF BIRTH ____________________ GENDER ______

  MOTHER'S  NAME    ________________________________ FATHER'S  NAME _______________________________________

  ADDRESS     _____________________________________________ CITY _________________________   ZIP CODE __________

  PHONE #     (      ) ____________________EMAIL_________________________________________________________________

   EMERGENCY CONTACT PERSON: _____________________________________________ PHONE # ______________________

  MEDICAL INSURANCE CO. _____________________________ POLICY # ____________________ PHONE # ________________

  List any Medical Problems, Allergies or Medications__________________________________________________________________

                                                                 RELEASE AND CONSENT AGREEMENT

The undersigned student  and/or parent or legal guardian of a student of The Gymnastics Training Center of Rochester Inc., by signing this contract, expressly acknowledges that this contract contains release and other risk-shifting provisions which may operate to shift risk from The Gymnastics Training Center of Rochester Inc., to the undersigned student and/or parent or legal guardian of a student of The Gymnastics Training Center of Rochester and the student and/or parent or legal guardian of a student of The Gymnastics Training Center of Rochester Inc., expressly accepts the responsibilities and duties resulting from such provisions.  The individual (s) signing this agreement admit (s) reading and understanding the terms contained in this agreement.  I  (we) the undersigned student and/or parent or legal guardian of a student of The Gymnastics Training Center of Rochester Inc.,  for and in consideration of enrollment and/or the enrollment of my child or a student for whom I have been granted legal custody hereby voluntarily and knowingly execute this release with the express intention of effecting the extinguishments  of and complete release from any and all claims, actions, demands or rights to monetary judgments whatsoever  arising  from any and all injury or physical harm which may occur to the student, including specifically those that may arise out of,  or be occasioned by, directly or indirectly, any  negligent act (s) or omission (s) of The Gymnastics Training Center of Rochester Inc.,  its officers, agents, employees or servants during the student’s attendance at and participation in any activities associated with The Gymnastics Training Center of Rochester Inc.,  both on and off  The Gymnastics Training Center of Rochester Inc.,  premises. 

                                                                     MEDICAL CONSENT AND RELEASE

I, the undersigned  parent or legal guardian of  the above named student do hereby expressly grant authority to the staff of The Gymnastics Training Center of Rochester Inc.,  to render a judgment concerning medical assistance in the event of an accident, injury or illness during  my absence and execute this consent and release provision with the express intention of effecting the extinguishments of and complete release from any and all claims, actions, demands or rights to monetary judgments whatsoever arising from any and all injury or physical harm which  may arise from the rendering of such judgments, including specifically those that may arise out of, or be occasioned by,  directly or indirectly, any negligent act (s)  or omission (s) of The Gymnastics Training Center of Rochester Inc., its officers, agents, employees or servants involved  in the rendering of such judgments.  Furthermore, in the case of an emergency I consent and expressly grant the staff of The Gymnastics Training Center of Rochester Inc., the authority to obtain medical assistance and treatment as they deem necessary.  I understand that neither The Gymnastics Training Center of Rochester Inc., its officers, agents, employees or servants shall be responsible for any medical expenses incurred on behalf of the above named student, and that I am responsible for all payment of medical expenses so incurred.

I give my express permission and consent for a licensed doctor or physician to administer the necessary aid to my child or legal ward (Name)_________________________ should he/she become injured or sick while in attendance at or while participating in any activity associated with The Gymnastics Training Center Of Rochester Inc., and to do so without having to wait until I (we) are contacted.

I HAVE READ, UNDERSTAND, AND EXPRESSLY AGREE TO THE ABOVE STATEMENT.   By the execution hereof I do further bind myself, my child or legal ward and all heirs, executors, administrators, successors or assigns of same.

SIGNATURE (PARENT/GUARDIAN): __________________________________________DATE ______________

Please print, fill out and submit this form in person to GTC, or Fax to (585) 388-0018. Or, fill out and send to gtc@frontiernet.net