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 January 21, 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:
- 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.”
- 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.
- 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.
- 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.
- 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.
- 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 January 21, 2019