The Hills Fitness Center Kid's Clubhouse
Information Sheet

Child's Name: _________________________________________
Date of Birth: _______________

List any allergies or medical history that we should be aware of:

 

Child's Name: _________________________________________
Date of Birth: _______________

List any allergies or medical history that we should be aware of:

 

Child's Name: _________________________________________
Date of Birth: _______________

List any allergies or medical history that we should be aware of:

 

Mother's Name: _______________________________________
Home Phone: ________________________
Work Phone: ________________________

Father's Name: _______________________________________
Home Phone: ________________________
Work Phone: ________________________

Emergency Contact:
Name: _______________________________________
Phone: ________________________

Name: _______________________________________
Phone: ________________________

Do you consent to the administration of minor First Aid to your child if needed? Yes___

Do you consent to our dispensing medication to your child at your request? Yes ___ No ___

Physician: _______________________________________

Address: _______________________________________
Phone: ________________________

I have received and read The Hills Health Club & Wellness Center Kid's Clubhouse Information Guide.

Signature of Parent: _______________________________________
Date: ________________________

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The Hills Fitness Center Kid's Clubhouse
Liability Release Form

Name: ____________________________________
Phone: ________________________________
Address: __________________________________
Work Phone :___________________________

Name of Child(ren)

_______________________________________ Date of Birth: ______/_______/_________

_______________________________________ Date of Birth: ______/_______/_________

_______________________________________ Date of Birth: ______/_______/_________

The undersigned does hereby release The Hill Fitness Center, its officer, agents and employees from any and all liability, of any kind whatsoever arising out of any physical or mental injury incurred or sustained by the undersigned son(s) and/or daughter(s) named above while he/she participates in any program while at The Hills Health Club & Wellness Center facility and this includes any injury sustained while using any equipment provided by The Hills Fitness Center. The undersigned acknowledges and affirms that he or she has carefully read this released and has asked and obtained a satisfactory explanation of any part that he or she does not understand.

Signature: _______________________________________
Date: ________________________

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The Hills Fitness Center

4615 Bee Caves Road, Austin, Texas 78746
512.327.4881