Block Therapy Student Registration & Waiver (etransfer, Cash or Interac/Debit Payment)

TO: Riviera Investments Ltd., carrying on business as Fluid Isometrics (“Fluid Isometrics”) & Jennifer Kroeker, carrying on business as Fitness with Jen

FROM: Type Name Below (along with his/her parents, legal guardians, heirs, administrators, executors and personal representatives, as the context requires, collectively referred to as, the "Student")

Name*

First NameLast Name

WHEREAS the Student has purchased block therapy instruction from Fluid Isometrics (the "Instruction") & Fitness with Jen;

NOWTHEREFORE, in consideration of Fluid Isometrics &/or Fitness with Jen providing the Instruction to the Student, the Student hereby agrees as follows:

1. The Student warrants that he or she is in good health and proper physical fitness to enable participation in the Instruction and any ancillary activities associated with the Instruction.

2. The Student warrants that he or she does not have any advanced, serious medical condition or any of the following conditions:

Pregnancy;
Implants
Pacemaker
Surgical mesh;
Surgery/scars
Broken bones
Spinal metal rods; or
Advanced Osteoporosis;
any of which may prohibit the Student from participating in the Instruction.

3. The Student hereby consents to his/her participation in the Instruction notwithstanding the potential risks, including healing crises, and the Student accepts and assumes all risks, whether known or unknown, and assumes all responsibility for any losses, costs and/or damages for any injury suffered by the Student by any means and howsoever caused and even if caused, in whole or in part, by the negligence of Fluid Isometrics &/or Fitness with Jen or any of Fluid Isometrics's or Fitness with Jen's employees, contractors, or agents (collectively referred to as, the "Released Parties") by the Student's participation in the Instruction and/or any activities associated with the Instruction.

4. The Student hereby waives, releases and forever discharges any and all claims or actions that the Student may now or in the future have against the Released Parties for any injury, damages or loss that the Student has or may sustain as a result of the Student's participation in the Instruction and/or any activities associated with the Instruction, including healing crises.

5. The Student acknowledges that he/she has read this Release, Waiver, Consent Assumption of Risk and Indemnity Agreement (the "Agreement"), fully understands its terms and conditions, and has accepted it freely and without any influence, and agrees that if any portion of the Agreement is held to be invalid, the balance notwithstanding, shall continue in full force and effect. Fluid Isometrics & Fitness with Jen hereby informs the Student of his/her right to obtain independent legal advice with respect to the Agreement. In the event that the Student signs the Agreement without obtaining independent legal advice, the Student agrees he/she will have done so voluntarily and without any undue pressure and the Student agrees that any such failure to obtain independent legal advice shall not be used by him/her as a defence to the enforcement of his/her obligations hereunder.

6. SESSION/CLASS TERMS & CONDITIONS:

1. Block Therapy sessions/classes that are not rescheduled or canceled 24 hours in advance will result in forfeiture of the session and a loss of the financial investment at the rate of one session/class. In the case of a pre-set session/class, the session/class missed will be forfeited.
2. Clients arriving late will receive the remaining scheduled session/class time, unless other arrangements have been previously made with the instructor.
3. Sessions/classes that have not yet proceeded are refundable subject to a 50% cancellation fee.

I HAVE READ THIS RELEASE, WAIVER, CONSENT ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Student Email

example@example.com

Student Signature

Date

Student Birth Date

MonthDayYear

This is to certify that I, as parent/guardian with legal responsibility for the Student, do consent and agree to his/her release, waiver, consent, assumption of risk and indemnity as provided above of all the Released Parties, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the Released Parties from any and all liabilities incident to my minor child’s involvement or participation in Instruction and any activities associated with the Instruction as provided above

Parent/Guardian Signature

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Number

Area CodePhone Number

How did you hear about Jen's classes?

Please indicate which option you would like to purchase:

5 Class Pass In Person – $85.005 Class Pass ONLINE - $68.0010 Class Pass In Person - $155.0010 Class Pass ONLINE - $124.00Single Class In Person – $20.00Single Class Online – $15.00Class Recording Only - $5.00 Can't make it but don't want to miss a class or want to do it at your own pace. (Sent after class with access for 1 week)Paying in cash, debit/interac; please come to class 15 minutes early to process; (advanced registration/waiver required)Paying by etransfer; send to: fitnesswithjen2@gmail.com or 204-955-0629 (advanced registration/waiver required)

Please indicate the class(es) you are registering for

Tuesdays 12:00p.m. – 1:00p.m. ONLINE from the comfort of your homeTuesdays 4:00p.m. – 5:00p.m. In Person @ @ 23159 Road 60 North just South of OakvilleWednesdays 5:00p.m. – 6:00p.m. In Person @ Just Be Wellness Studio, Portage La PrairieFridays 12:00p.m. - 1:00p.m. In Person @ 425-5th Ave in Oakville

Please indicate the Date you would like your pass to begin and/or any additional details (You can register for multiple classes at once; however when a pass is purchased an assumed schedule will be sent to you)

Block Therapy Student Registration & Waiver Form