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Health info, emergency contacts, media release, and helmet options

FLYING GRAVITY CIRCUS programs include but are not limited to: Performance Troupes, Pre-Troupe, Open Training, Summer Tour, Silver Lining Circus Camp, Adult Classes, Private Lessons, Circus After School Programs, Circus Workshops and Circus Residencies.

THIS FORM MUST BE COMPLETED IN FULL AND RETURNED TO FLYING GRAVITY CIRCUS PRIOR TO THE FIRST DAY OF PROGRAM.

 

In the event I cannot be reached in an emergency, I hereby give permission to the FLYING GRAVITY CIRCUS STAFF to secure proper treatment for the person named below. I expect to be notified immediately.

I Agree

I hereby authorize FLYING GRAVITY CIRCUS staff to administer and medication(s) I have indicated below to my child/teen as indicated. I understand that there is no physician on site at FLYING GRAVITY CIRCUS programs.

I Agree

Now select who will be participating and the remainder of the form will open in the next window.

 

 

First Participant's Name

First Name*

Last Name*

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

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First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information

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Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information

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Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information

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Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information

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Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information

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Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information

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Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information

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Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information

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Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information

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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*
Student Information

Nickname (if any)

School Attended

Current Grade

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Emergency Contacts

If parents are unavailable in an emergency, please include the name, phone number, and relationship to the student of a person we may contact. *
Permission for Pick Up

Please include information for ANY PERSONS you authorize to pick up your children from our programs. INCLUDE YOURSELF. If a name is not listed below, staff will not release your child to that person. Please make every effort to list people that may be picking up your child during the program, including grandparents, siblings, friends, etc. *
Health History (answer and give approximate dates)

Has your child ever require hospitalization? *

Operations or serious injuries? (list dates) *

Dietary modifications or allergies? *
Epipen or inhaler needed?*

Date of Last Physical *

Any specific activities that your child cannot participate in? *

Any additional information you think we should know?

Name of Family/Child Physician *

Phone number of family/child physician *

Name and address of preferred emergency facility/hospital
This health history is correct as far as I know and the person listed has permission to engage in all prescribed FLYING GRAVITY CIRCUS activities except as noted.*
Yes
No
Medications/Remedies
The following is a list of medications the Flying Gravity Circus staff may have on site (not guaranteed) and may have available to administer to your child if a need arises. Please check the box next to any medication that you DO GIVE PERMISSION for Flying Gravity Circus staff to administer.
Arnica (topical)
Tylenol/acetaminophen (oral)
Advil/Ibuprofen (oral)
Benadryl (oral)
Neosporin (topical)
Calendula (topical)
Badger Balm Muscle Rub (topical)
Here please indicate if there are any remedies/medications you do NOT GRANT PERMISSION for FGC staff to administer.
Arnica (topical)
Tylenol/acetaminophen (oral)
Advil/Ibuprofen (oral)
Benadryl (oral)
Neosporin (topical)
Calendula (topical)
Badger Balm Muscle Rub (topical)

Please indicate here if your child REQUIRES any medications to be taken during the program. Please include the following: Drug Name, Route (oral, topical, etc.), Dosage, Schedule and Indications, Comments/Side Effects, and your initials.
Media Release
I give FLYING GRAVITY CIRCUS permission to take and reproduce photographs, video, and/or other recordings of ny child/teen while he/she is participating in any FLYING GRAVITY CIRCUS program, in person or on-line. I give FLYING GRAVITY CIRCUS permission to include my child/teen's name, age, and town of residence along with photographs and/or video and/or other recordings, and to provide this information to the media. I agree that FLYING GRAVITY CIRCUS shall have exclusive rights to use, and to authoriaze others to use the material resulting from said photographs and/or video and/or other recordings in any way FLYING GRAVITY CIRCUS wishe, including but not limited to using it on publicity materials including the FLYING GRAVITY CIRCUS website, CIRCUS AFTER SCHOOL PROGRAM website, advertising, films, interviews, documentaries, books, television productions, and brochures, in print and/or electronic media including Facebook, Instragram, and sometimes in presentations by our staff for educational purposes.*
Yes
No
Helmet

Part of the Flying Gravity Circus experience is learning to unicycle! This is a fun and challenging skill which, like any circus activity, is accompanied by a certain level of risk. While a student of unicycling will likely encounter minor scrapes and bruises along the way, serious injury during regular circus practices or performances is unlikely, though possible.

Helmets and wrist guards are commonly used in "off road" or "extreme" unicycling on dirt bike paths or challenge courses (which are not the activities of this program). We advocate wearing helmets whenever a unicyclist is traveling on roads where cars, bicycles, pedestrians, and potholes can prove hazardous to the unicyclist although our research has not found any New Hampshire statute requiring children or teens to wear helmets while unicycling. In youth circus programs nationwide, students usually do not wear helmets while unicycling.

We realize that families have different policies around helmet-wearing, so we prefer to leave this decision in YOUR hands. You may prefer to have your child use a helmet, or you may feel fine without a helmet, or you may choose a combination (to use a helmet in the early learning stages, then stop using it as the child/teen becomes more confident). The decision is yours. (If you prefer your child to be helmeted while unicycling, please send a labeled bicycle helmet with your child. Your child will only be allowed to ride while wearing it.)

Thank you!

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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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

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

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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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