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“THE CONFIDENCE BUILDING GYM”

HIGH ENERGY GYMNASTIX ❖ 636.532.7762 ❖ hinrggymnastix.com
140 LONG ROAD, CHESTERFIELD MO, 63005 ❖ 1676 HIGHWAY K, O'FALLON MO, 63366 ❖ 9930 HIGHWAY N, O'FALLON MO, 63367 ❖ 54 THE LEGENDS PARKWAY, EUREKA MO, 63025

Synder Insurance Services, Inc.

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

In consideration of participating in the High Energy Fitness LTD dba High Energy Gymnastics (Hi-NRG) class or other program, I represent that I understand the nature of this Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue participation in the Activity. I fully understand that this Activity involves risks of serious bodily injury, including permanent disability, paralysis, and death, which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the “releasees” named below; and that there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, cost, and damages I incur as a result of my participation in the Activity.

I hereby release, discharge, and covenant not to sue High Energy Fitness LTD dba High Energy Gymnastics (Hi-NRG), its respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the Activity takes place, (each considered one of the “RELEASEES” herein) from all liability, claims, demands, losses, or damages, on my account caused or alleged to be caused in whole or in part by the negligence of the “releasees” or otherwise, including negligent rescue operations and future agree that if, despite this release, waiver of liability, and assumption of risk I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost, which any may incur as the result of such claim.

I further acknowledge, understand, appreciate and agree that my participation may result in possible exposure to and illness from infectious diseases, including, but not limited to, MRSA, Influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation and exposure.

I have read the RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.

I give permission to High Energy Fitness LTD dba High Energy Gymnastics (Hi-NRG) to take photos of my child/children for use in marketing/advertising within the establishment including social media, newsletters, posters, and other advertising. I give permission to High Energy Fitness LTD dba High Energy Gymnastics (Hi-NRG) to contact me via text or email

High Energy Fitness LTD dba High Energy Gymnastics (Hi-NRG) gives safety of the student the highest priority, employing competent, trained instructors and using the best equipment and safety aids available. If there should be an accident, we will make EVERY EFFORT to contact the child's parents FIRST. IF WE CANNOT get in touch with you, then we MUST have authorization to secure medical treatment. I hereby authorize High Energy Fitness LTD dba High Energy Gymnastics (Hi-NRG) to secure medical treatment for my child in any emergency which may occur while he/she is under our supervision.

We recommend wearing comfortable, athletic clothing to class. Clothing should be properly fitted to your child and mid sections must be covered. Leotards and shorts for girls are recommended. No jewelry or gum is permitted on the gym floor. If your child has long hair it must be pulled back away from the neck and face for safety. No shoes are allowed on the gym floor. Please note - cheer shoes are permitted for tumbling classes if approved by the coach.

Today's Date: January 19, 2021

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Name of Group or Event

Food Allergies

Medical Conditions
First Participant's Signature*
Second Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Third Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Fourth Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Fifth Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Sixth Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Seventh Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Eighth Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Ninth Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Tenth Participant's Name

First Name*

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

Name of Group or Event

Food Allergies

Medical Conditions
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent/Legal Guardian Information

Address

Zip Code

Phone Number *
PARENTAL CONSENT: AND I, the minor’s parent and/or legal guardian, understand the nature of the above referenced activities and the Minor’s experience and capabilities and believe the minor to be qualified to participate in such activity. I hereby Release, discharge, covenant not to sure and AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS each of the Releasees from all liability, claims, demands, losses, or damages on the minor’s account caused or alleged to have been caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations, and further agree that if, despite this release, I , the minor, or anyone on the minor’s behalf makes a claim against any of the above Releasees, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS each of the Releases from any litigation expenses, attorney fees, loss liability, damage, or cost any Releasee may incur as the result of any such claim.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Name of Group or Event

Food Allergies

Medical Conditions
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.


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