Team Health Form & Waiver

Competitive Team Health Form & Waiver

Gymnasts Information

* Indicates required field

Name *

Age *

Birthdate *

Address *

City, State, Zip *

Home Phone *

Team T-Shirt Size *

Health Information

Special Limitations or Concerns *

Chronic Health Conditions *

Taking Medications or Medication Allergies? *

Doctor's Name/Office *

Phone Number *

Insurance Carrier *

Insurance # *

Parents/Guardians Information

Parent/Guardian 1 *

Parent/Guardian 1 - Cell Phone # *

Parent/Guardian 2 *

Parent/Guardian 2 - Cell Phone # *

email Address *

Parent T-Shirt Size *

In case of emergency, and we are unable to reach the parents/guardians, please provide an alternate contact:

Name *

Phone # *

Relationship *

Waiver Information

I authorize the YMCA of Greater Westfield to use my child’s photo/image for marketing and promotion purpose *

Yes No

I understand that every effort will be made to reach me in case of emergency. If I am unable to be contacted, I hereby authorize the staff at the YMCA of Greater Westfield to act in my absence according to their best judgement in any emergency requiring medical attention, and hearby waive and release the YMCA from any and all liability for any injuries incurred during the gymnastics season. I understand that participation in gymnastics involves motion, rotation and height in a unique environment and as such carries the risk of injury. I hereby authorize qualified medical personnel to administer necessary emergency treatment to my child in the event of an accident in which I cannot be reached. By signing below I authorize my child to participate in the YMCA gymnastics program and understand and agree to the terms and conditions. *

I Have Read & Understand

Parents Signature *

Date *

Submit

Competitive Team
Health Form & Waiver

Competitive Team Health Form & Waiver

Gymnasts Information

Health Information

Parents/Guardians Information

Waiver Information

Links

Our Location

Competitive Team​Health Form & Waiver

Competitive Team Health Form & Waiver

Gymnasts Information

​Health Information

Parents/Guardians Information

Waiver Information

Links

Our Location

Competitive Team
Health Form & Waiver

Health Information