Birthday Party/Open Gym Waiver 330 Washington Ave. La Grange, IL 60525 708-352-2977 Child's Name* First Last GenderGenderMaleFemaleDate of Birth* Health concerns or limitations (allergies, injuries, etc.) or other special circumstances that we should be aware of for this student:*Address* Street Address City State / Province / Region ZIP / Postal Code Email Home PhoneWork PhoneEmergency Contact Person* First Last Parent's Names ASSUMPTION OF RISK-WAIVER OF LIABILITY- INSURANCE STATEMENT-MEDICAL AUTHORIZATION I recognize that severe injuries, including permanent paralysis or death can occur in sports or activities involving height or motion, those activities including but not limited to gymnastics, tumbling and trampoline. Being fully aware of these dangers, I hereby give consent for my child to participate in any and all Gemini Gymnastics Academy, LLC programs and activities and I ACCEPT ALL RISKS associated with this participation. In consideration for my child’s participation I hereby, for myself and my child and our respective heirs and successors, COVENANT NOT TO SUE and FOREVER RELEASE Gemini Gymnastics Academy, LLC, its officers, directors, shareholders, employees, contractors and volunteers from all liability that results in damages or injuries as a result of participation including those from acts of negligence. I also hold Gemini Gymnastics Academy, LLC harmless against any accident or injury that may occur to anyone entering Gemini Gymnastics Academy, LLC property. This is to include occurrences during the dropping off, picking up and/or waiting for the participant of classes as well as birthday parties. In any event of an accident or emergency I hereby authorize my child to be transported to a hospital for medical treatment and I hold Gemini Gymnastics Academy, LLC and its representatives harmless in the execution of such. Additionally, I affirm that the above identified student is covered by medical insurance and I hereby agree to individually provide for all medical expenses which may be incurred by me or my child as a result of any injury sustained while participating at or for Gemini Gymnastics Academy, LLC. I have read and understand this ASSUMPTION OF RISK and WAVIER OF LIABILITY and INSURANCE STATEMENT and MEDICAL AUTHORIZATION and VOLUNTARILY affix my name in agreement. PHOTO RELEASE I am aware that individual or group publicity photos or videos may be taken from time to time and in consideration for my or my child(ren)'s participation I hereby grant my permission for my child's likeness to be used in publicity or advertising. I also understand and give permission for photographs and videos of named persons and/or participants and/or myself be used in print or broadcast media as deemed appropriate for the promotion of Gemini Gymnastics Academy. If you are in a situation that legally doesn't allow photos please let us know. We can ensure Gemini Gymnastics Academy doesn't post or use your child in pictures but due to the nature of today's electronics we cannot control our clients. Parent's / Legal Guardian's Agreement to Waiver I Agree By Checking the "I Agree" below you are agreeing to the conditions stated above and confirm that the information provided is true and accurate.