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Parent First Name

Parent Last Name

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Child First Name

Child Last Name

Child Date of Birth

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Child First Name 2

Child Last Name 2

Child Date of Birth 2

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Child First Name 3

Child Last Name 3

Child Date of Birth 3

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I affirm that neither my child nor I, nor any other immediate family member, has experienced fever (temperature above 100.4 F) in the last 72 hours.

I affirm that neither my child nor I, nor any other immediate family member, has experienced any signs of illness, including but not limited to runny nose, cough, sore throat, shortness of breath, chills, etc. in the last 72 hours.

I agree that neither my child nor I, nor any other immediate family member, has had contact with anyone with a suspected or confirmed COVID-19 case in the last 14 days.

I hereby give my consent to my child(ren)'s participation in MY GYM activities and hold MY GYM harmless from any and all liability for any injuries or damages that I or my child(ren) may suffer in connection with the activities sponsored by MY GYM.

In case of an emergency when I cannot be reached, I authorize the staff of MY GYM to obtain whatever medical treatment deemed necessary for the welfare of my child(ren).

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