Free Class Registration/Informed Consent Form

What class(es) would you like to attend?

Yoga Flow (Mondays Sep. 8th-Nov. 24th from 7:30-8:15pm)Zumba (Thursdays Sep. 11th-Nov. 27th from 7:30-8:15pm)In-person (Bolton)Virtual (Zoom)

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Answer Yes/No *

	YES	No
Has your doctor ever said that you have a heart condition or high blood pressure?
Do you feel pain in you chest at rest, during your daily activities of living, or when you do physical activity?
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing including during vigorous exercise).
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
Are you currently taking prescribed medications for a chronic medical condition?
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?
Has your doctor ever said that you should only do medically supervised physical activity?

*If you answered yes to one of the questions above then a seperate questionnaire will be emailed to you prior to class.

Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability. Feel free to ask questions by emailing Melanie at shake.it.like.a.mama@gmail.com.

Purpose*

I understand that in my participation, exercises involved may include \ activities such as dancing, stretching, and muscular conditioning using body weight.That I am participating in group fitness offered by Shake It Like a Mama, during which I receive information and instruction about healthy and safe practice. I recognize that these classes may require physical exertion, which may be strenuous and could result in physical injury, and I am fully aware of the risks and hazards involved.

Risks*

I understand that during the conduct of exercise, the reaction of my heart, lungs, and blood vessels, etc., cannot be predicted with accuracy, thus risks may arise due to adverse changes of that may lead to heart attack, high blood pressure, or stroke.I was given information and I understand that during training, injuries may arise such as muscle, ligaments, joints and tendons; and in I have been given proper information in order to prevent or minimize these occurrences.I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which me or my child, might incur as the result of participating in the program. I agree to inform my instructor of any physical limitations, physical discomforts and/or injuries before or during classes, and I take full responsibility for nondisclosure

Waiver*

I understand that I shall solely be responsible, and that Shake It Like a Mama shall not be held liable for any damages and injuries arising from the fitness training program.I hereby release and fully and forever discharge Shake It Like a Mama, its assigns and agents from any and all claims, demands, and/or damages therein.

Confedentiality*

I am aware that all information obtained by Shake It Like a Mama from me, such as fitness records, personal information, among others, shall be treated as confidential information and that Shake It Like a Mama holds these information as privileged information. These information shall not be disclosed nor shared to anyone.I grant Shake It Like a Mama the permission to use photos and/or videos of myself taken during class on social media such as Facebook and Instagram for marketing purposes.

By signing this form, I have had the opportunity to ask questions and those were answered to my satisfaction. I understand all the terms, my rights, as well as my obligations herein. I voluntarily give my consent and I declare that I was not induced or coerced into signing this form.

Age Verification*

I am of legal age and I am legally competent to give my consent to this agreement.

Signature*

Registration and Informed Consent Form