DWL Registration Form w/ 26.2

Welcome to Dance Walk Live!

PARTICIPANT INFORMATION FORM
Full name*

First NameLast Name
Birth Date*

MonthDayYear
Gender

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Dietary Preferences
What is your dietary preferences? i.e. Vegan, Vegetarian, Paleo, Keto, etc.
Do you have any dietary restrictions? i.e. Nut Allergies, Diabetic, etc.
Health Questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not take part in physical exercise?

I have read, understood and completed this questionnaire.
Fitness Level: How many days per week do you exercise?

01-23-56-7
Initials*

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Liability Waiver/ Disclaimer
I am aware of the risks in observing or participating in the activities offered and sponsored by Dance Walk Live and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or loss whatsoever. It is understood that Dance Walk Live is not responsible for any damage that would be resulting from any coaching, plans, suggestions, tips or programs of Dance Walk Live- the show, social media sites and its representatives.

Please refer to the website dancewalklive.com for the full Terms and Conditions, Waivers and Disclaimers.
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Cancellation Policy
You may cancel at any time. There is no obligation to remain whatsoever.
If you want to end your contract with us, please have the courtesy of letting us know by doing the following:
Email us at letsmove@dancewalklive.com. Please provide your name, home address, your phone number and email address telling us of the reason you wish to cancel.

Please refer to the website dancewalklive.com for the full Terms and Conditions, Waivers and Disclaimers.
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Member Signature
Signature*

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Date

JourMoisAnnéeAM/PM Option

Movement Marathon

26.6 Miles of Movement Challenge
DWL's Miles of Movement Marathon is a 6-week challenge where participants accumulate 26.2 miles of movement within 6 weeks.

Activities include walking, runing, treadmill, cycling, stationary cycling, elliptical, stairmaster, wheel chair, swimming, hiking, dancing, crawling, skiing, rowing, pushing, skating and any other type of movement as long as you're MOVING! Our goal is simply to inspire you to your personal 26.2!

Log your miles with any smart device and email the results once you've completed your 26.2 to earn your Certificate of Completion and finisher's medal!

REGISTRATION IS NOW OPEN and closes October 31st, midnight!

Challenge Start Date: October 4th 2021

Challenge Finish Date: November 24th, 2021, midnight

Registration earns you free memebership to DANCE WALK LIVE thru December 31st, 2021. ($7/ month starting Jan 15th 2022. You may cancel your membership at any time).

Mile of Marathon registration is only $26.20! (plus shipping and handling- International rates may apply).
Add one or both of the following items!

Miles of Movement Unisex T-Shirt, add $10.00Finisher's Medal, add $5.00
Please refer to the website dancewalklive.com for details, full Terms and Conditions, Waivers and Disclaimers.
Participant Signature
Signature*

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Should be Empty:

Welcome to Dance Walk Live!

Dietary Preferences

Health Questionnaire (Par-Q)

Liability Waiver/ Disclaimer

Cancellation Policy

Member Signature

Movement Marathon

Participant Signature