Notice To The Minor Child'S Natural Guardian (Page 2 of 2) in pdf

Gymnast is voluntarily participating in these activities with knowledge of the risk involved, and I hereby agree, on behalf of

myself and Gymnast, to accept any and all inherent risks of property damage, personal injury or death.

3. I further agree to indemnify, defend and hold harmless U.S. GOLD, its directors, officers, employees, teachers,

coaches, agents and assigns for any and all claims arising as a result of Gymnast’s engaging in or receiving instruction in

U.S. GOLD activities, or any activities incidental thereto, whenever, wherever or however the same may occur.

4. I understand that this waiver is intended to be as broad and as inclusive as permitted by the laws of the State of Florida

and agree that if any portion is held invalid, the remainder of the waiver will continue in full force and effect.

5. I affirm that I am the parent/legal guardian of the Gymnast named herein and am freely signing this Waiver and

Release of Liability. I have read this Waiver and Release of Liability and fully understand that by signing same I am giving

up, on behalf of myself and Gymnast, legal rights and/or remedies which may be available to me, or Gymnast, for the

ordinary negligence of U.S. GOLD, its directors, officers, employees, teachers, coaches, agents and assigns.

6. I hereby certify that Gymnast is covered by medical insurance through _________________________________ (name

of insurance company) which will cover the Gymnast in the event of an injury. I assume full responsibility and liability for

any and all expenses connected with an injury and/or illness that is not paid by my insurance company or through military

benefits, if the Gymnast is entitled to military privileges. I further certify I will notify U.S. GOLD if there is any change in

this insurance coverage. I understand I am required to have in place appropriate medical insurance for this Gymnast

before he or she will be allowed to participate in the activities described herein.

PART II – EMERGENCY MEDICAL AUTHORIZATION

In the event reasonable attempts to reach me at the phone numbers stated above have been unsuccessful, I give my

consent for (a) the administration of any treatment deemed necessary by ______________________(preferred physician)

or ____________________ (preferred dentist), or in the event the designated preferred practitioner is not available, by

another physician or dentist, and (b) the transfer and admission of the child to ____________________ (preferred

hospital) or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical

opinions of two other licensed physicians or dentists concurring in the necessity for such surgery are obtained prior to the

performance of the surgery. I hereby authorize any treating physicians to provide information to U.S. GOLD officials

regarding Gymnast’s medical condition or injuries. Facts concerning the Gymnast’s medical history, including allergies,

medications being taken and any physical impairments to which a physician or dentist should be alerted (list or write

“none”): ______________________________________________________________

MEDICAL PROVIDERS MAY ACCEPT A PHOTOCOPY OF THIS SIGNED AUTHORIZATION AS IF IT WERE AN ORIGINAL FOR ALL PURPOSES

THIS WAIVER AND RELEASE OF LIABILITY DISCLAIMER, AND EMERGENCY MEDICAL

AUTHORIZATION, SHALL REMAIN IN EFFECT UNTIL ONE YEAR FROM THE DATE BELOW

By signing below, I verify that I have read, reviewed and completed all parts of this Waiver and Release of Liability

Disclaimer and Emergency Medical Authorization form and know it contains a RELEASE.

____________

________________________________

_____________________________________

DATE

Printed Name of Parent/Guardian

Signature of Parent/Guardian

___________________________________

Witness

Notice To The Minor Child'S Natural Guardian Page 2