Class Participation Form

Class Participation Form

Once you've completed this form, Sam will e-mail you the class log-in details.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday*

MonthDayYear
Date
Emergency Contact Name*

First NameLast Name
Emergency Number*

Area CodePhone Number
How did you hear about us?
Agreement of Release and Waiver of Liability
Initial Below: By signing this document, I acknowledge that I am participating in exercise sessions offered by Samantha Zilvitis, in person and/or online, live and/or recorded, either privately or in a group setting, during which I will receive information and instruction about health and fitness. I recognize that fitness programs require physical exertion which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.*

I agree
Initial Below: I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the exercise sessions. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the exercise sessions.*

I agree
Initial below. In consideration of being permitted to participate in the exercise sessions, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the exercise sessions.*

I agree
Initial Below: In consideration of being permitted to participate in the exercise sessions, I knowingly, voluntarily and expressly waive any claim I may have now or in the future against Samantha Zilvitis for injury or damages that I may sustain as a result of participating in the exercise sessions.*

I agree
Initial Below: I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Samantha Zilvitis for any injury or death caused by her negligence or other acts.*

I agree
I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.*

Clear
Thank you for agreeing to the terms and conditions stated above. Please type out your full name.*
If participant is under 18 years of age. Name of Parent/Legal Guardian of Participant:

First NameLast Name
Phone Number of Parent/Legal Guardian of Participant:

Area CodePhone Number
Signature of Parent/Legal Guardian of Participant

Clear
Parent/Legal Guardian: Thank you for agreeing to the terms and conditions stated above. Please type out your full name.
Don't forget to click the SUBMIT button below. Sam will e-mail you the class log-in details once she's received your completed form. THANKS!
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Class Participation Form

Agreement of Release and Waiver of Liability