Name *

First Name

Last Name

Emergency Contact *

First Name

Last Name

Heart Disease

Yes

No

Shortness of Breath or Chest Pain

Yes

No

Inhaler

If yes, make sure to bring it to every class

Yes

No

High Blood Pressure

Yes

No

Significant Bone/Joint/Muscle Pain

Yes

No

Back Pain

Yes

No

Cigarette Smoking

Yes

No

Abnormal Resting EKG

Yes

No

Diabetes

Yes

No

Insulin dependent

Yes

No

SECTION III: AGREEMENT *

1. In consideration of participating in the “Activity”, I agree and acknowledge that I am fully aware that participation in the Activity involve risks and I accept all the risks of participating, even if the risks are created by the carelessness, negligence or gross negligence of a Released Party (as defined below) or anyone else. 2. “Claims” includes but is not limited to any and all liabilities, claims, demands, legal actions, rights of actions for damages, personal injury or death in connection with participation in the Activity. “Released Party” means Jennifer Stackpole Palmer or any of her affiliates, franchisees and their respective representatives, directors, officers, agents, employees or volunteer staff. 3. I agree and acknowledge that: a. I am in proper physical condition to participate in the Activity, and am aware that participation could, in some circumstances, result in physical injury, serious physical injury or death. b. I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured. c. I am aware that if the Activity occurs outdoors, the streets adjourning the area of the Activity are open to regular vehicular traffic during the Activity and I will obey all traffic laws and regulations. 4. I accept full responsibility for any product or technology loaned to me as part of participation in this Activity and commit to return the same in good working order. 5. I hereby, for myself and for my heirs, next of kin, executors, administrators and assigns, fully release, waive and forever discharge any and all rights or Claims I may have, now or in the future, against any Released Party, even if the Claims are based on the carelessness, negligence or gross negligence of a Released Party or anyone else. Without limiting the foregoing, I further release any recourses which I may now or hereafter have resulting from any decision of any Released Party. 6. I agree not to sue any Released Party for Claims, even if the Claims arise from the carelessness, negligence or gross negligence of any Released Party or anyone else. I agree to indemnify (reimburse for any loss) and hold harmless each Released Party from any loss or liability (including any reasonable legal fees they may incur) defending any Claim made by me or anyone making a Claim on my behalf, even if the Claim is alleged to or did result from the carelessness or negligence of any Released Party or anyone else. 7. I am aware that there is no obligation for any person to provide me with medical care during the Activity. I understand and acknowledge that: a. there may be no aid stations available for the Activity. b. if medical care is rendered to me, I consent to that care if I am unable to give my consent for any reason at the time the care is rendered. 8. I am aware that it is advisable to consult a physician prior to participating in the Activity. If I have consulted a physician, I have taken the physician’s advice. 9. No warranties or representations have been made to me about the Activity which are not stated on this form. I understand and intend that this document act as the broadest and most inclusive assumption of risk, waiver, release of liability, agreement not to sue and indemnity. 10. If any provision of this agreement shall be unlawful, void or for any reason unenforceable, then that provision shall be deemed severable from this agreement and shall not affect the validity and enforceability of any remaining provisions. 11. I have fully read and understand this agreement. I am aware that by signing this agreement, I am waiving certain legal rights I or my heirs, next of kin, executors, administrators and assigns may have against the Released Party.

Yes

I understand all payments are non-refundable or transferrable for any reason, including, but not limited to vacation, illness and injury. *

Yes

I understand It is my soul responsibility to check with my doctor or medical practitioner about my suitability for training and to obtain his/her written consent where necessary. While we take every care to ensure safe practices, there are inherent risks in any exercise programme and we accept no liability whatsoever for any injury or illness you incur through our classes or by your failure to notify us of any existing health problems or special needs. *

Yes

48 HOUR CANCELATION POLICY *

I understand as a courtesy to staff and clients, a 48 hour cancellation notice must be given for all scheduled sessions. Sessions cancelled without this notice will be charged at the full session rate. Cancelled sessions without a 48 hour notice are non-transferable and non-refundable.

Yes

I understand the scheduling and content of activities may be changed on occasion. *

Yes

I will notify the instructor immediately of any pain and/or major discomfort felt during any activity. *

Yes

I understand I am responsible for bringing my required equipment to every activity (where applicable) *

Yes

BY CHECKING BELOW, Participant accepts and agrees to the terms and provisions contained in this agreement. *

Yes