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Camp Medical Form
Camp Medical Form
Medical Form
Select Camp
*
TOT CAMP, Ages 3-5yrs, 9:00am-12:00pm
TUMBLING CAMP, Ages 6 and up, 12:30-3:30pm
FULL DAY CAMP, Ages 6 and up, 9:00am-3:30pm
Camper's Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Date of Birth
*
MM slash DD slash YYYY
Sex
*
Male
Female
T-Shirt Size
*
Child Extra Small
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Adult Extra Large
Please select your camper’s t-shirt size.
Parent/Guardian Name
*
First
Last
Parent/Guardian Daytime Phone
*
Emergency Contact Name (other than parent)
*
First
Last
Relationship to Camper
*
Emergency Contact Phone
*
Does your child have any health problems that might impair his/her activity at camp (previous fractures, ADHD, etc.)?
*
No
Yes
If yes, please explain, or note N/A:
Please list any other pertinent information that might be needed at camp (i.e., allergies, medications to be given, etc.)
Consent
*
I have read and give consent to the statement below.
I understand and accept the risks of injury inherent to participating in gymnastics. Furthermore, 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(ren) to participate in the Carroll Gymnastics, Inc. programs and activities. I accept all risks associated with such participation. In consideration for me or my child(ren)’s participation I hereby, for myself and my child(ren) and our respective heirs and successors, promise not to sue and forever release their respective officers, directors, employees, landlords and volunteers from all liability resulting from damages or injuries incurred as a result of participation. In the event of an accident or emergency, every effort will be made to contact the parents or guardian. If necessary, I give my consent to Carroll Gymnastics, Inc. to administer first aid and/or authorize my child(ren) to be transported to a hospital for medical treatment and I hold Carroll Gymnastics Inc. and their representatives harmless in the execution of such. I agree to be responsible for any medical bills incurred by myself for my child(ren) resulting from illness or injury sustained while participating at or for Carroll Gymnastics, Inc. Additionally, I release all photos taken of my child by the Carroll Gymnastics staff for publicity purposes (brochures & website only). I have read and understand this assumption of risk, waiver of liability, medical authorization, and photo release and I voluntarily select this box in agreement.
Name of Consenting Adult
*
First
Last
Date
*
MM slash DD slash YYYY
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