(320)251-FLIP
806 Sundial Drive Waite Park, MN 56387
*Release Form
Granite City Gymnastics Release Form:
Child's name:
____________________________________________________________________________________________
(Last) (First) (Middle)
Second Child's Name:
____________________________________________________________________________________________
(Last) (First) (Middle)
Father's Name:_____________________
Mother's Name:_____________________
Home Address:__________________________________________
City:___________________ Zip:___________________
Birthdate:_______________________
Phone:
Mother's
Home:_________________________Work:___________________________Cell:_________________________
Father's
Home:_________________________Work:___________________________Cell:_________________________
Alternate Emergency Contact Name:______________________________
Phone: (home)________________________ (0ther)______________________________
Insurance Information:
Insurance Company:__________________________________________
Policy Number:________________________________
Policy Holder:___________________________ Relationship to Child:_________________________
Place of Employment:_________________________________________
Other:
Allergies:___________________________________________________________________________
Medications:________________________________________________________________________
Family Physician and Phone Number:_________________________________________________________
Child's name:
____________________________________________________________________________________________
(Last) (First) (Middle)
Second Child's Name:
____________________________________________________________________________________________
(Last) (First) (Middle)
Father's Name:_____________________
Mother's Name:_____________________
Home Address:__________________________________________
City:___________________ Zip:___________________
Birthdate:_______________________
Phone:
Mother's
Home:_________________________Work:___________________________Cell:_________________________
Father's
Home:_________________________Work:___________________________Cell:_________________________
Alternate Emergency Contact Name:______________________________
Phone: (home)________________________ (0ther)______________________________
Insurance Information:
Insurance Company:__________________________________________
Policy Number:________________________________
Policy Holder:___________________________ Relationship to Child:_________________________
Place of Employment:_________________________________________
Other:
Allergies:___________________________________________________________________________
Medications:________________________________________________________________________
Family Physician and Phone Number:_________________________________________________________
