North West Ohio Elite Athletics

122 Empire Street, Montpelier, OH 43543

E-mail: NWOEliteAthletics@yahoo.com

Gymnastics_______ Cheer Team________ Cheer Class _______ Tumbling________

2019 REGISTRATION FORM
Participant’s Name: ____________________________________________________________
Birthdate: _________________ Age: __________________ Grade:_______________________
E-mail Address: ________________________________________________________________
Parent’s Name: ________________________________________________________________
Address:__________________________________________ City: _______________________
State __________ Zip: ___________ Athletes Cell Phone: ______________________________

Nwo Elite is authorized to give my child the following medication: (circle) Tylenol Advil Benadryl

Notes:

EMERGENCY MEDICAL FORM

Participant’s Name:______________________ Athletics Brace required: Yes____ No____ Kind___________

Father’s Name: __________________________ Work Phone: ______________ Cell Phone: ______________

Mother’s Name: _________________________ Work Phone: ______________ Cell Phone: ______________

Family Doctor: ___________________________________________ Office #: _________________________

Medical Insurance Carrier: _________________________________ Plan #: ___________________________

Emergency Contact ____________________________________ Phone# _____________________________

Confidential health history: Does the participant have any conditions or take any medication that may
affect participation in cheerleading/gymnastics? YES or NO

If yes, explain:_____________________________________________________________

_______________________________________________________________________

PERMISSION FOR MEDICAL TREATMENT: In the event my son/daughter becomes ill or sustains an injury while in the care of or under
the supervision of North West Ohio Elite Athletics or it’s leaders, consent is given to admit him/her to any hospital facility for all
medical, surgical, diagnostic and hospital procedures for him/her when such treatment is deemed immediately necessary or
advisable to safeguard my son/daughter and it is not advisable or possible to return him/her to me or receive my instruction on
his/her care. I wave my right to informed consent for said treatment.

DATE: ___________________ PARENT’S SIGNATURE:______________________________________________