Kingdom Gymnastics

2000 Memorial Drive  (Mailing: PO Box 326) St. Johnsbury Center, Vt. 05863

Birthday Party  -  Open Gym  -  Special Event Release Form

Name of participant: ___________________________________________________________ DOB: _______________

Address: __________________________________________________________________ Phone: ____________________

Parent’s Name (if participant is under 18) __________________________________________________________

Emergency Contact Name and Phone #: _____________________________________________________________

Do you authorize Kingdom Gymnastics to use the images of the student/parents, both with and without name identification, for Kingdom Gymnastics publicity, promotional and advertising purposes?   YES      NO

Rules and Obligations: No one under 18 will be allowed to leave the gym to wait for their ride. All participants who enter the gym area for a birthday party or Open Gym, MUST sign a release form. Proper clothing must be worn; no jeans with snaps or zippers; no jewelry, no socks can be worn on the tumble track or balance beams. No food allowed beyond the waiting area. All participants are obligated to follow safety rules. Kingdom Gymnastics reserves the right to ask a participant to leave the gym area, if safety rules are being consistently violated. No refunds will be given. Children 5 and under must be accompanied and supervised by a parent during Open Gym.

Parent/Guardian Waiver and Release: I fully understand that Kingdom Gymnastics staff members are not physicians or medical practitioners of any kind. With the above in mind, I hereby authorize and release Kingdom Gymnastics to render temporary first aid to my child in the event of any injury or illness, and if deemed necessary by Kingdom Gymnastics staff, to seek additional medical help and/or call an ambulance. I am aware that my son/daughter will be engaging in physical exercise involving activities that could cause injury to them. I agree that my child is voluntarily participating in these activities and we are assuming all the risks of injury, including total disability, paralysis and even death that might result. I hereby agree to waive any claims or rights against Kingdom Gymnastics, LLC and it’s staff for any liability, loss, costs, damage, medical expense, long-term care, emotional distress or compensation that might incur as a result of these activities. I also agree to waive any claims against Kingdom Gymnastics should my child, myself, or any member of my family, be diagnosed with Covid-19, or any other infectious disease, that could possibly be traced to another person attending Kingdom Gymnastics, whether it be a student, coach, staff member or other parent.

Parent/Guardian Signature________________________________________     Date___________________