Please CLICK HERE for Disclaimer/Waiver
A waiver is needed for each individual. Please fill this out legibly in case we need your contact information
Insurance Waiver
Parent/Guardian Information
Child’s last name ______________________________ First name: ____________________ Age: _____ Date of Birth: ____________
Health conditions: _____________________________________________________________ E-mail address: _______________________________________________________________ Parent or Guardian Name: ______________________________________________________ Address: ____________________________________________________________________________ City: ___________________________________ State:__________ Zip: __________________ Home phone: _______________________ Work phone: ______________________________ Emergency contact: _____________________Emergency phone number: _______________ Insurance Provider_______________________________________________________ Policy or Suscriber number________________________________________________
I have enrolled my child in a program of physical activity. I hereby affirm that he/she is in good physical condition and does not suffer from any disability that prevents or limits his/her participation in this exercise program. In consideration of my child’s participation in Gold Medal Excellence All-Sports Training and Conditioning program, I hereby release Gold Medal Excellence All-Sports Training and Conditioning (employees and owners), from any claims, demands and causes of action arising from his/her participation with Gold Medal Excellence All-Sports Training and Conditioning.
I realize there are physical risks when participating in a program of physical activity. I hereby release Gold Medal Excellence All-Sports Training and Conditioning from any liability now or in the future including, but not limited to, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries and any other illness, soreness or injury however caused, occurring during
or after my child’s participation in a Gold Medal Excellence All-Sports Training and Conditioning , individual session, group session, team session, camp or clinic.
I have read, understand and accept all policies.
Parent’s signature: ______________________________________Date____________________________
Referred By: ___________________________________________________________
Return to Christopher Asher, Moriah Jubrey, Michelle Vaughner or at training session or mail to 1730 Camino Palmero #404, LA, CA 90046
Please CLICK here to get the Gold Medal Excellence Liability Insurance Waiver