Loading...

Thank you for choosing Virginia Techniques! Our mission at Virginia Techniques Gymnastics is for students to reach their full potential safely, happily, and successfully. Our structured programs help kids develop self-esteem, confidence, coordination, flexibility and strength while having fun!

Medical Authorization Form

I understand that I will be contacted as soon as possible if my child is injured and in need of medical attention. I understand that my child may be taken to the nearest emergency room/hospital for treatment if Virginia Techniques Gymnastics, Inc. (VTGI) staff deems it necessary.

In the event I am unavailable to provide parental consent, I hereby authorize the physician(s) and staff in the emergency room to provide care that may include diagnostic procedures and medical treatment as necessary to my minor child. I also authorize the release of all x-rays, test results, lab work or any other procedures that would be helpful in the follow-up care of my child. This medical treatment is to be given to my child without any further permission from the undersigned. A photocopy of this authorization shall be considered as effective and valid as the original.

I, the undersigned, authorize payment of medical benefits to the medical facility for any services furnished to my child by the physician(s) or staff. I understand that I am financially responsible for any amount not covered by my insurance provider. I also authorize release of information concerning health care, advice, treatment or supplies provided to my child while attending VTGI activities to my insurance company. This information will be for the purpose of evaluating and administering the benefit claims. This consent is valid as long as my child is participating in VTGI activities.

I have read and understand the Medical Authorization Form prior to signing it. The participant information given is true and accurate. Furthermore, I understand that I am responsible for notifying VTGI and updating this information if it changes at any time during my child’s membership at VTGI.

I Agree

May 25, 2019

Release of Liability Waiver

By signing this document you will waive certain legal rights, including the right to sue.

I recognize that potentially severe injuries can occur in any activity involving height or motion including tumbling and related activities. I am aware that in addition to the usual dangers and risks inherent in the sport of gymnastics and other Virginia Techniques Gymnastics, Inc. (VTGI) activities, certain additional dangers and risks are present when using a gymnastics facility including, but not limited to, the danger and risk of falling, jumping, landing, misdirected moves, performing tricks and colliding with other participants, staff, and spectators. By signing this waiver, I freely accept and fully assume responsibility for all such dangers and risks and the possibility of personal injury, permanent paralysis, death, or loss resulting thereof.

In consideration of being allowed to participate in any way in the Virginia Techniques sports program, I acknowledge, appreciate, and agree:

  1. To waive any and all claims for personal injury including death, permanent paralysis, illness, and/or property damage that I may have against VTGI, Virginia Techniques Booster Club, Inc., their partners, principals, shareholders, directors, officers, affiliates, agents, employees, contractors, representatives, and any volunteers in any way associated with VTGI all of whom are hereinafter collectively referred to as “the Releasees.”
  2. To release the Releasees from any and all liability for any loss, damage, injury, permanent paralysis, death, medical or other expense that I may suffer or that any other party may suffer as a result of my participation in VTGI’s sports program, and in transport to and from gymnastics meets and other Releasees designated activities, due to any cause whatsoever.
  3. To hold harmless and indemnify the Releasees from any and all liability for any property damage or personal injury to any third party, resulting from my use of any gymnastics facilities and equipment or by my participation in the sport of gymnastics and other Releasees activities.
  4. This release of liability shall be effective and binding upon my heirs, next of kin, executors, administrators, successors, and assigns in the event of my personal injury including death, permanent paralysis, illness and/or property damage.
  5. I agree not to take unreasonable risks while participating in gymnastics and other Releasees activities, including but not limited to attempting skills or tricks that I am not qualified to perform safely or causing any other participants/spectators unreasonable risk of harm. Furthermore, I agree to follow correct safety procedures when using gymnastics facilities, equipment and all Releasees activities away from the gym.
  6. I also expressly grant to the Releasees the right to film, videotape, photograph, record and make any reproductions of my physical likeness and voice, and the irrevocable right to perpetuity to use, display, and digitally enhance or alter in any manner, such likeness in any media.

I certify that I have read and understand this Release of Liability Waiver prior to signing it, and I am aware that by signing this Release of Liability Waiver I am waiving certain legal rights which I or my heirs, assigns, personal representatives, next of kin, executors, administrators, successors, and assigns, may have against the Releasees.

VTGI shall have the right to impose any additional conditions which, in the opinion of the Releasees, will further the intent and legal rights and waivers provided herein.

This Release of Liability Waiver was made and executed in the state of Virginia and shall be governed by, enforced in, and construed in accordance with the laws of the State of Virginia.

I hereby consent to participating in programs at Virginia Techniques Gymnastics, Inc. (VTGI) as stipulated.

I Agree

May 25, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Medical Preferences
Hospital Preference*

Physician's Name
Adult Participation

Insurance regulations require all participants to be age 22 or under to participate in classes or activities at Virginia Techniques Gymnastics, Inc.

Parents and legal guardians participating in Bunnies classes may be older than 23 as long as they have a signed waiver on file. 

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above. Adults participating in Bunnies class must sign the waiver for their minor child and themselves. All adults participating in Bunnies must have a waiver signed.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Does the participant have any medical and/or social conditions?*

What are the symptoms of this condition?
Does the participant have any food allergies?*

Please list all food allergies:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver