Youth Gymnastics Event Medical Release Form

Participant Information

Participant Full Name

Date of Birth

Address

City

State

Zip Code

Parent/Guardian Information

Parent/Guardian Name

Relationship

Primary Phone

Email

Emergency Contact (Other Than Parent/Guardian)

Name

Phone

Relationship

Medical Information

Primary Physician Name

Physician Phone

Insurance Provider

Policy/Group Number Please list any allergies, medications, or medical conditions:

Medical Release and Authorization

I, the undersigned parent/guardian of the above-named participant, authorize the event organizers to secure emergency medical treatment as deemed necessary in my absence. I hereby release and waive all liability from the Youth Gymnastics Event, its representatives, and volunteers.

Parent/Guardian Signature

Date