Fitness Class Registration Participant Name Date of Registration Event Registering for Personal Training Small Group Training Hatha Yoga Bindaas Bollywood Dance Fitness Date of Birth Participant Age Email Contact Number Full address City State Zip Emergency Contact Name Emergency Contact Phone Number Family Physician Name Family Physician Phone Number General Information Must be 12 or older to participate in the Bollywood Bindass Fitness class; kids under 16 must be accompanied by parents. Childcare will not be provided for this fitness class. Have you ever been advised not to exercise by a medical doctor? Yes No Do you have any of the following medical conditions? Disease Arthritis High Blood Pressure Asthma Diabetes Hyperglycemia Joint Problems Other None Are you on any medication? Yes No Do you have a medical condition we should know about? Liability Waiver Release Form Due to the physical demands of exercise, I recognize that this fitness class may involve strenuous physical activities including muscle strength training, cardiovascular conditioning, and endurance training. I understand that there is a risk of personal injury by participating in this fitness program such as muscle strains, muscle pulls, muscle tears, shin splints, heat exhaustion, knee injuries, back injuries, foot injuries, broken bones, heart attacks, and possibly death. I, for myself, and on behalf of my heirs, assigns, personal representatives, and next of kin, hereby Release and Hold Harmless Jayanthi Murahari, members/officers, agents, and employees of and from any claims, demands, actions, or causes of action for all injuries, disabilities, or death, that I might suffer as a result of the use of the facility or equipment therein. Whether arising from the ordinary negligence of Jayanthi Murahari, or otherwise. I have carefully read this RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT and understand the terms of this agreement. By filling this form, I agree to the above-mentioned Terms and Conditions. Name Date Submit
