Lawrence G-Force, LLC
PLEASE PRINT AND FILL OUT COMPLETELY
Today’s Date: _____/_____/_____
Name: ______________________________________________________ DOB: _____________________________
PARENT OR LEGAL GUARDIAN INFORMATION
Name: ___________________________________________Home Phone: ___________________Cell Phone: ____________
In case of an emergency please notify:
Name: _______________________________________Phone: ____________________ Relationship: __________________
2nd person to notify (other than parent or guardian in case of an emergency):
Name: _______________________________________ Phone: ____________________ Relationship: __________________
MEDICAL INFORMATION (PLEASE CIRCLE YES OR NO)
Heart Condition
Yes - No
Asthma
Yes - No
Diabetes
Yes – No
Allergic to Medication
Yes - No
Convulsion, Seizure, Disorders
Yes - No
Allergic to Insect Stings
Yes – No
State any Allergies:
Date of Last Tetanus Shot:
Additional Medication information that may be helpful:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Any Medications Receiving:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
INSURANCE INFORMATION
Insurance Company Name: _________________________________________________________________________
Policy #: ________________________________________________ Group # (if any): ___________________________
Insured’s Name______________________________________Relationship:____________________________________
Medical Release Form
I, certify that ___________________________________________________________is physically capable and able to
fulfill requirements needed to be a cheerleader and performer. I further understand this form legally releases all
obligations and responsibilities for the medical treatment of my son/daughter in the event of illness or injury during any
squad related activity when either parent cannot be reached. If there is any physical or medical reason why he/she should
not participate fully, the Lawrence G-Force, LLC organization, its coaches, agents, staff, requires a doctors (physicians)
release. Furthermore, Lawrence G-Force, LLC, its coaches, and agents are NOT liable for any injury incurred during
cheerleading.
The undersigned as parent or guardian gives consent for the cheerleader/participant to engage in cheerleading activities
as representatives of the Lawrence G-Force, LLC organization, and to accompany the team as member on its many,
camp, clinics, events, competitions, and trips.
Medical Treatment Release Form
The undersigned as the parent/legal guardian of the above mentioned do hereby consent to any and all medical
treatments, including , ambulance transport, anesthesia, and operations which may be deemed advisable by any qualified
physician selected by the agents of officials of Lawrence G-Force, LLC. The intention hereof is to grant authority to
administer and perform all and singularly any examination, treatments, anesthetics, operations, and or diagnostic
procedures, which may now or during the patients care be deemed advisable or necessary by any qualified physician. No
action will be taken until an attempt is made to contact me at the phone number (s) listed.
Signature of Parent or Legal Guardian ________________________________ Date _____________________________
DISCLAIMER: LAWRENCE G-FORCE, LLC IS NOT RESPONSIBLE FOR ANY INJRY (OR LOSS OF PROPERTY) TO ANY
PERSON WHILE PRACTICING, TAKING CLASS, COMPETING, PARTICIPATING IN OPEN GYM, BIRTHDAY PARTIES,
OR IN ANY OTHER WAY INVOLVED IN POWER TUMBLING & TRAMPOLINE, CHEERLEADING, OR ANY OTHER
ACTIVITY PROVIED BY LAWRENCE G-FORCE, LLC FOR ANY REASON WHATSOEVER, INCLUDING ORDINARY
NEGLIGENCE ON THE PART OF LAWRENCE G-FORCE, LLC, ITS OWNERS, OFFICERS, AGENTS OR EMPLOYEES.
In consideration of my participation, I hereby release and covenant not-to-sue Lawrence G-Force, LLC, the Jet Boosters, an any of
heir employees, teachers, coaches, or agents, from any and all present and future claims resulting from ordinary negligence on the part
of Lawrence G-Force, LLC or others listed for property damage, personal injury, or wrongful death, arising as a result of my engaging
in said activities with Lawrence G-Force, LLC, including but not limited to activities directly associated with Lawrence G-Force, LLC
on and off the premises. I hereby voluntarily waive any and all claims resulting from ordinary negligence, both present and future,
that may be made by me, my family, estate, heirs, or assigns.
Further, I am aware that power tumbling & trampoline and cheerleading are vigorous sporting activities involving height and rotation
in a unique environment and as such they pose a risk of injury. I understand that power tumbling & trampoline, cheerleading, and
related activities always involve certain potential for minor to catastrophic injury including death. The risk of harm may be limited by
all of the safety equipment and trained coaches, but never eliminated. I am voluntarily participating in this activity with knowledge of
the risks involved and hereby agree to accept any and all inherent risks of property damage, personal injury, or death.
I further agree to indemnify and hold harmless Lawrence G-Force, LLC and all others listed for any and all claims arising as a result
of my engaging in or receiving instruction in Lawrence G-Force, LLC activities referred to within this release.
I understand that this waiver is intended to be as broad and as inclusive as permitted by the laws of the state of Kansas and agree that
if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for
any legal proceedings shall be within the state of Kansas. In the event of an emergency or non-emergency situation requiring medical
treatment, I hereby grant permission for any and all medical and/or dental attention to be administered, in the event of an accidental
injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid,
the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical
personnel.
I affirm that I am of legal age and am freely signing this agreement for myself as well as for my minor children. I have read this form
and fully understand that by signing this form, I am giving up legal rights and or remedies which may be available to me for the
ordinary negligence of Lawrence G-Force, LLC or any person listed or described above.
________________________________________________________________________
Signature of Parent
Date
`````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````
Before me, the undersigned authority, on this day personally appeared ____________________________________, known to be the
person whose name is subscribed above, and acknowledged to me that he/she excuted the same for the purpose therein expressed.
Sworn and subscribed before me this _____ day of ________________, __________________.
Notary Public Signature: ______________________________________
Notary Public for _________________________ County, Kansas
My Commission expires: ___________________________________