Stoughton Gymnastics, LLC 

 201 W Main Street

Stoughton, WI 53589

Participation & Liability Waiver

Please list all children in your family on this single waver

Participant’s Name: __________________________________ Birthday: __________ Age: _____    Female __ Male __

Medical Insurance: Yes No___

Please list any medical conditions and/or relevant information that will assist us in teaching your child:

_______________________________________________________________________________________

Participant’s Name: __________________________________ Birthday:__________ Age: _____ Female __ Male __

Medical Insurance: Yes No___

Please list any medical conditions and/or relevant information that will assist us in teaching your child:

_______________________________________________________________________________________

Parent’s Name: ____________________________________________________________________________

Home Address: City & Zip: ___________________________________________________________________

Cell:__________________________________     Cell:____________________________________________

EMAIL Address(es):_________________________________________________________________________

Parent agrees to the Participation Liability Waiver and Consent, as described below

Parent Signature required: ______________________________________________      Date: ________________________

Participant Liability Waiver & Medical Treatment Consent:

I, the undersigned parent/guardian of the listed student, do hereby grant the authority to the staff of Stoughton Gymnastics to render judgment concerning medical assistance in the event of an accident, injury, or illness. I further authorize simple first aid, a medical or surgical diagnosis and treatment which may be deemed necessary. By the very nature of the activity, gymnastics, tumbling & trampoline and other sporting activities carry a risk of physical injury. NO matter how careful the student and coach are, no matter how many spotters are used, no matter what height is used or what landing surface exits, the risk cannot be eliminated. The risk of injury includes minor injuries such as bruises and more serious injuries such as broken bones, dislocations and muscle pulls. The risk also includes, and always includes catastrophic injuries such as permanent paralysis or event death from landings or falls on the back, neck or head. I hereby waive and hold harmless any and all Stoughton Gymnastics LLC. staff and other staff working in conjunction with Stoughton Gymnastics and any and all facilities and transportation vehicles Stoughton Gymnastics. deems necessary to use or teach from or be associated with-whether paid or volunteer-for any injuries, claims or damages in conjunction with Stoughton Gymnastics. I understand that as any athletic activity that involves motion or height, participation creates the possibility of injury. I have read and understand the risks involved in my child’s/ward’s participation at Stoughton Gymnastics. I hereby consent and wish to have my child/ward actively participate at Stoughton Gymnastics. Photo Release: I agree that photos of my child or me may be used for publicity for Stoughton Gymnastics (inside the gym, newspaper, website, Facebook, mailings, etc).