Agreement of Release and Waiver of Liability
This release form covers ALL classes you attend with Samantha Zilvitis of Padma Fitness & Yoga.
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
E-mail
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example@example.com
Phone Number
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Format: (000) 000-0000.
Physical Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
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Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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.
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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.
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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.
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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.
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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.
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I agree
I am 18 years of age or older. 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.
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Thank you for agreeing to the terms and conditions stated above. Please type out your full name.
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If participant is under 18 years of age, please complete a release form for minors. Thank you.
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