OVER THE TOP GYMNASTICS ACADEMY, INC .
11 MCKEON ROAD
WORCESTER, MA 01610
508-752-7676
**Please note: In order for your child to participate in the gymnastics
activities, we must have the following information completed
and returned to Over The Top Gymnastics Academy.
PERMISSION SLIP
Child’s Name:_____________________________________ Age:______ Date of Birth_______________
Child’s Name:_____________________________________ Age:______ Date of Birth_______________
Parent’s Name:______________________________________________
Address:____________________________________________________
City:____________________________ Zip Code:________________
Home Phone:___________________ Cell Phone:_____________________ Work Phone:____________
Email address__________________________________________________________________________
Emergency Contact:____________________________________ Phone #_________________________
List allergies:______________________________________________________________________
_______________________________________________________________________________
Medical Insurance Name:___________________ Doctor’s Name and Phone ______________________
In consideration of your accepting this application, I the undersigned intending to be legally bound, hereby for
myself, my heirs, executors and administrators, waive and release any and all rights and claims I may have against
Over The Top Gymnastics Academy and its employees, successors and assigns for damages, injuries and / or claims
which I might otherwise have arising out of said event. I attest and verify that I am physically fit for the sport of
gymnastics. My physical condition has been verified by a licensed medical doctor. If signed by a parent, the parent
agrees to release and hold the above named organization and persons harmless of any claims and / or rights which
may be asserted by or on behalf of the application. The parent also agrees to permit any photos taken of their child
in class to be used for advertising purposes.
__________________________________________________ _________________________
Signature of parent or guardian Date
*FOR BIRTHDAY PARTIES, FIELD TRIPS, OPEN GYM, GROUP OUTINGS