Assumption of Risk, Waiver of Liability, Medical Authorization


Dutchess County Gymnastics Center

Assumption of Risk, Waiver of Liability, Medical Authorization

In consideration for my participation in classes, training, events and activities at Dutchess County Gymnastics Center, Inc. (known hereon as “DCGC”), I agree to be bound by the following conditions:

Eligibility:  I agree to comply with all the rules and regulations of DCGC which have been provided and reviewed by me.  I understand that activities may be photographed by DCGC employees and used for the purposes of marketing or promotion for DCGC.  Names will not be used without written permission from parents or legal guardians.

Readiness to Participate:  I/my child will only participate in those classes, events, competitions and activities for which I believe I/he/she is physically and psychologically prepared.  Prior to participation, I/he/she will have practiced my/his/her exercises and will perform only those exercises that I/he/she have accomplished to a degree of confidence necessary to assure that I/he/she can perform them myself/himself/herself, and without injury.

I understand that it is my responsibility to be aware and make my child aware of the possibility of injury and encourage my child to follow all the safety rules and the coaches’ instructions.

Waiver and Release:  I understand that participation in gymnastics and cheerleading activities, including tumbling, stunting, use of any equipment and/or apparatus carries an inherent risk of physical injury.  I also understand that the risk cannot be eliminated even when the student and instructor are careful, no matter how many spotters are used and no matter what height is used or what landing surface exists.  The risk of injury includes minor injuries such as bruises, cuts and scrapes and more serious injuries such as broken bones, dislocation of joints, muscle pulls and ligament/tendon damage. The risk also includes catastrophic injuries such as temporary or permanent paralysis or even death from landings or falls on back, neck or head.

In exchange for my/my child’s participation in classes, training, events and activities, I release, discharge and agree to indemnify and hold harmless Dutchess County Gymnastics Center, Inc., its employees, officers or agents (the Released Parties) from any liability, loss or damage, including but not limited to that arising from negligence of any of the Released Parties, which may result to me or any minor child of mine, except where such loss or damage is the result of intentional or reckless conduct of one of the Released Parties identified above.

Medical Attention:  I fully understand that DCGC staff members are not physicians or medical practitioners of any kind.  I hereby authorize DCGC staff to render temporary first aid to myself or my child in the event of an injury or illness.

I hereby give my consent to DCGC and/or the host organization to provide, through a medical staff of its choice, customary medical/athletic training attention, transportation and emergency medical services at my expense or insurance coverage only as warranted in the course of my/my child’s participation.

I also affirm that I am required to have and will continue to provide proper hospitalization, health and accident insurance coverage which I consider adequate for both my child’s protection and my own protection.  I understand that the costs of all medical attention are my responsibility and not that of DCGC.


Child’s Full Name        Date of Birth   

Child’s Full Name        Date of Birth   

Child’s Full Name        Date of Birth   

Parent’s Full Name        Phone Number   

Street Address 

City        State         Zip Code   

I hereby attest that I am the legal parent or guardian of this child, and I verify by my signature below that I fully understand and accept each of the above conditions for permitting me and/or my child to participate in classes, training, events, camps, competitions and activities conducted by Dutchess County Gymnastics Center, Inc.  I further acknowledge receipt of all rules and regulations of DCGC. My participation and/or my child’s participation in this activity is purely voluntary and I elect to participate knowing the risks. 

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Dutchess County Gymnastics Center https://dutchessgymnastics.com
Signature Certificate
Document name: Assumption of Risk, Waiver of Liability, Medical Authorization
Unique Document ID: f5fd7845ccdb041885f9dd115346722f13002bda
Timestamp Audit
December 20, 2018 6:07 pm EDTAssumption of Risk, Waiver of Liability, Medical Authorization Uploaded by Jeremy Keilly - jeremy@dutchessgymnastics.com IP 174.44.103.52
December 20, 2018 6:47 pm EDTDutchess County Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52
December 21, 2018 3:53 pm EDTDutchess County Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52
January 3, 2019 10:24 am EDTDutchess County Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52