First Name: Middle Initial: Last Name:

Age:    Date of Birth:

Address:

City: State: ZIP:

Home Phone: Cell Phone:
Email Address:

Mother's Name: Mother's Work Phone:
Father's Name: Father's Work Phone:

Has the info above changed in the last year? YesNo
I give permission for my gymnast's photo to appear on the website or Facebook page. YesNo

How did you hear about Andy Valley Gymnastics?

1. Does the participant have any existing medical problems? NoneAsthmaDiabetesSeizuresHeart ProblemsMusculoskeletal Problems (ex: back, neck, bone, or joint problems, scoliosis)Other (please explain)
2. Does the participant have to use medications on a regular basis? yesno If yes, what medication and use?
3. Does the participant wear any appliances/devices? NoneEyeglasses/contactsHearing AidsDental AppliancesSplints/OrthoticsOther (please explain)
4. Does the participant have any medical conditions that might interfere with his/her participation in the sport of gymnastics? If yes, what condition?
5. Does the participant have any known allergies? If yes, please specify:

Emergency contact name: Emergency contact phone:
Doctor’s Name: Phone:
Insurance Company: Phone: Hospital Preference:

Emergency Medical Care Authorization: In the event that the Participant should become accidentally injured or ill while at Andy Valley Gymnastics (AVG) or any related activity in which the participant may be involved, we hereby authorize AVG or AVG agents to arrange for whatever emergency medical care is deemed necessary and reasonable at the time, including transport to a local hospital Emergency Dept. and agree to be solely responsible for all expenses and costs related to such emergency treatment and agree to indemnify and hold harmless AVG, its shareholders, directors, officers, employees, coaches, agents and Parent Association for any expenses and costs it may incur related to such treatment.

Consent & Release: We hereby consent that the Participant above may be involved in gymnastics and any related activities provided by AVG. We unconditionally release, hold harmless, waive, discharge and covenant not to sue Andy Valley Gymnastics, its shareholders, directors, officers, employees, coaches, agents and Parent Association from any & all liability for damages and costs and any claim or demand therefore, directly or indirectly arising out of or related to any injuries that the above named Participant might sustain while engaged in the practice or performance of any gymnastic activity while at Andy Valley Gymnastics or at any event in which the Participant, Andy Valley Gymnastics, employees, coaches, agents or Parent Association are involved.