Loading...

Gymstarz Elite, LLC

Student Release Form

Today's Date: December 22, 2024

IN CONSIDERATION of allowing the student named above to enroll at Gymstarz Elite, LLC and use of the premises of Gymstarz Elite, LLC and Starz Align LLC, the undersigned, being the legal and acting guardians of the student, acting for themselves and/or on behalf of the student, release and hold harmless Gymstarz Elite, LLC, Starz Align LLC, its owners, employees, and agents of and from any and all liability , claims, demands, actions, and causes of action whatsoever, arising out of or related to any loss, property damage, or personal injury, including death, that may be sustained by the student and/ or the undersigned, while in or on the premises upon which the program is conducted, or incurred while in or on any premises tinder the control or supervision of Gymstarz Elite, LLC, Starz Align LLC, its owners, employees, and agents, or incurred while in route to or from any said premises, or incurred while on any other premises or place while undertaking activities of whatever kind or nature related to activities sponsored by or participated in by Gymstarz Elite, LLC, it owners, employees, and agents.

The undersigned, being duly aware of the risks and hazards inherent in participation in dance, martial arts, karate, tricking, self defense, trampoline, gymnastics, tumbling, jumps, stunting, cheering, summer camp, water play, outside play, coaching and other movement activities being conducted by Gymstarz Elite, LLC, and acting for themselves and the student, herby elect voluntarily to enter upon said premises under the control of Stephanie Meza, Starz Align LLC, Gymstarz Elite LLC, employees, staff and coaches. The undersigned, acting for themselves and the student, hereby voluntarily assume all risks of loss, property damage or personal injury, including death, which may be sustained by the student and/ or the undersigned, while in, or on said premises described above.

The owner may, but shall not be obligated to carry insurance on the student and/or the undersigned, and the existence if insurance shall not change, alter, or increase the liability of the owner to the student and/or the undersigned or affect the terms of this release.


This release shall be binding upon the distributes, heirs, next of kin, personal representatives, executors and administrators of the student and each of the undersigned.

The undersigned gives Gymstarz Elite, LLC the right to use any type of photography and video of the above student taken during any gymnastics event in which Gymstarz Elite, LLC is participating in, for website, advertisement and or business use.


In signing the release, each of the undersigned hereby acknowledges and represents: a) That he or she has read the foregoing release, understand, it, and signs voluntarily: b)That the undersigned signing as "legal guardian" is in fact a true legal guardian of the student; each of the undersigned is over 21 years of age and of sound mind, and has signed this release with the knowledge and consent of the participant, and each of the undersigned understands that this release related to any and all claims of the student and the undersigned. c) That participation in Gymstarz Elite, LLC gymnastics program may have an element of inherent danger or risk, and take full responsibility for my actions and physical condition. d) To indemnify and hold harmless Gymstarz Elite, LLC , Starz Align LLC, coaches, workers, committee members, and host teams from liability, loss. Cost. Or expenses (including but not limited to all fees, medical, and ambulance costs) that may incur while participating in said programs and or competitions.

First Gymnast's Name

First Name*

Last Name*

Phone*
First Gymnast's Date of Birth*
First Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
First Gymnast's Signature*
Second Gymnast's Name

First Name*

Last Name*
Second Gymnast's Date of Birth*
Second Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Third Gymnast's Name

First Name*

Last Name*
Third Gymnast's Date of Birth*
Third Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Fourth Gymnast's Name

First Name*

Last Name*
Fourth Gymnast's Date of Birth*
Fourth Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Fifth Gymnast's Name

First Name*

Last Name*
Fifth Gymnast's Date of Birth*
Fifth Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Sixth Gymnast's Name

First Name*

Last Name*
Sixth Gymnast's Date of Birth*
Sixth Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Seventh Gymnast's Name

First Name*

Last Name*
Seventh Gymnast's Date of Birth*
Seventh Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Eighth Gymnast's Name

First Name*

Last Name*
Eighth Gymnast's Date of Birth*
Eighth Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Ninth Gymnast's Name

First Name*

Last Name*
Ninth Gymnast's Date of Birth*
Ninth Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Tenth Gymnast's Name

First Name*

Last Name*
Tenth Gymnast's Date of Birth*
Tenth Gymnast's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
Gymnast'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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

School:

Grade:

Doctor's Name:

Office Phone:

If the family Doctor listed above cannot be reached in the event of a medical emergency (the existence of said emergency to be determined in the sole discretion of Gymstarz Elite, LLC, it owners, employees, or agents) I, we hereby authorize treatment to be rendered by the Emergency Room Physician at the following hospital:


PLEASE USE HOSPITAL:

Does the student have any medical problems teaches should be aware of?

Does the student have any physical defects which would slow progress such as: Weak or fallen arches, foot with turns in or out when walking, weak knees, etc.? If yes, please explain.

Is there anything we should be aware of that will help us teach your child effectively? Please list:
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 - TRY IT FREE!