SPEAKers with Sneakers!

Name*

First NameLast Name

Age*

Date of Birth*

Date

Preferred Pronouns*

She/Her/HersHe/Him/HisThem/They/TheirsOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Number*

Emergency Contact*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Relationship*

Check each BRONX, 9am Spring session you want to attend:

Saturday, May 3rdSaturday, May 17thSaturday, May 30thSaturday, June 14th

Check each BRONX, 9am Summer session you want to attend:

Check each BRONX, 9am Fall session you want to attend:

For and in consideration of SPEAK Initiative, Inc. permitting the participant to enroll and participate in the SPEAK Initiative, Inc. Event (“Event”), Participant, by signing below, hereby voluntarily indemnifies, releases from liability, and holds harmless SPEAK Initiative, Inc., the SPEAK Initiative, Inc. Team and affiliates, the facility for any accident, injury, illness, death, loss, damage to person or property, or other consequences suffered by Participant or any other person arising or resulting directly or indirectly from Participant’s participation in the event.

In the event that Participant is injured, Participant agrees to assume any financial obligation, either through Participant’s personal health insurance, or through some other means, for any medical costs which Participant incurs. SPEAK Initiative, Inc. assumes no responsibility for any medical expenses, injury, or damage suffered by Participant in connection with the use of any facilities or services in connection with the Activity.

IT IS THE INTENTION OF PARTICIPANT BY SIGNING BELOW TO EXPRESSLY ASSUME ALL RISK OF PERSONAL INJURY, DEATH, OR PROPERTY DAMAGE AND/OR LOSS UPON HIM/HER/THEMSELVES, TO THE EXCLUSION OF SPEAK INITIATIVE, INC. AND TO EXEMPT AND RELIEVE SPEAK INITIATIVE, INC. FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE AND/OR LOSS OR WRONGFUL DEATH.

Participant further agrees that Participant, his/her spouse, assignees, heirs, guardians, and legal representatives will not make any claim against, sue or attach SPEAK Initiative, Inc. for any loss or damage resulting from Participant’s participation in the Activity.

SPEAK Initiative, Inc Event Waiver/ Release Of Liability

PARTICIPANT IS AWARE OF THE POTENTIAL DANGERS INCIDENTAL TO ENGAGING IN THE FITNESS ACTIVITIES IN THE EVENT. PARTICIPANT AGREES THAT THIS IS A RELEASE OF LIABILITY, A WAIVER OF THE PARTICIPANT’S LEGAL RIGHT TO COLLECT DAMAGES IN THE EVENT OF INJURY, DEATH OR PROPERTY DAMAGE AND/OR LOSS AND A CONTRACT BETWEEN PARTICIPANT AND SPEAK INITIATIVE, INC. AND PARTICIPANT SIGNS IT OF HIS/HER/THEIR OWN FREE WILL.

My signature also acknowledges my agreement that I may be videotaped, audio recorded and/or photographed during the SPEAK Initiative, Inc. event, and SPEAK Initiative, Inc. may use and modify the images and/or recordings for any and all uses, including but not limited to advertisements and marketing without any compensation and in perpetuity.

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WE RECOMMEND THAT YOU WEAR COMFORTABLE CLOTHING AND SHOES AS WELL AS BRING ANY WATER OR BEVERAGES THAT YOU MAY NEED DURING THE ACTIVITY.

Email*

example@example.com

By adding your email, this will confirm your registration and agreement to the terms above.

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