Montgomery NCNW Stomping Out Diabetes

Health & Wellness Event

National Council of Negro Women, Montgomery Alabama Capital Section
Stomping Out Diabetes

Join us for line dancing and Zumba!
Location:

Eastdale Mall

Address:

1000 Eastdale Mall

Montgomery Alabama 36117

Date:

November 1th

Check-in Time:

9:30 am - 10:00 am

Time:

10:00 am - 12:00 pm
Participant Information
Your Name*

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Event Liability Waiver and Release Form
Name*

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I hereby acknowledge and fully understand the potential dangers incidental to engaging in dance, fitness and/or exercise activities, and acknowledge and understand that such activities require physical effort and exertion. I further acknowledge and agree that: 1. I am responsible for consulting my physician or other health care provider prior to enrolling and participating in a dance, fitness and/or exercise activity to determine whether participating in the activity is appropriate for me. 2. I will not enroll in or participate in dance, fitness and/or exercise activity if my physician or health care provider advises against it. 3. If I experience faintness, dizziness, pain or shortness of breath at any time during the dance, fitness and/or exercise activity that I will stop immediately and contact my physician or health care provider.*

I agreeI disagree
I acknowledge and understand that my participation in a dance, fitness and/or exercise activity could result in my exposure to bodily injury, illness, loss or death, as well as property losses and/or damage to property. For and in consideration of NCNW MAC permitting me to enroll and participate in the dance, fitness and/or exercise activities, and in recognition of the possible dangers to which I voluntarily subject myself by participating in the dance, fitness and/or exercise activities and related activities, I HEREBY AGREE AS FOLLOWS: 1. I hereby voluntarily for myself, my spouse, assignees, heirs, guardians or personal representatives, from the date of entry into this Waiver and Release, hold NCNW MAC and the Instructors teaching the dance, fitness and/or exercise activity I enroll and participate in, as well as their agents, employees, officers, directors, spouses, assignees, heirs, guardians or personal representatives blameless and waive any and all rights and causes of action and associated costs for any accident, injury, illness or death, occasioned by my participation in the dance, fitness and/or exercise. 2. In the event I am injured, I voluntarily agree to assume any financial obligation, either through personal health insurance, or through some other means, for any medical costs which I incur and NCNW MAC and the Instructors teaching the dance, fitness and/or exercise activities assumes no responsibility for any medical expenses, injury, or personal damage suffered by me in connection with the use of any facilities or services in connection with the NCNW MAC or the dance, fitness and/or exercise activities. 3.I hereby voluntarily assume all risk of damage or loss to my property while participating in the dance, fitness and/or exercise activities and relieve NCNW MAC and the Instructors teaching the dance, fitness and/or exercise activities from liability for any and all property damage or loss. 4.You acknowledge and agree that by signing up the NCNW MAC Health and Wellness Event, you are submitting a legally binding electronic signature and are entering into a legally binding contract. You acknowledge that your electronic submission constitutes your agreement and intent to be bound by these terms. Pursuant to any applicable statutes, regulations, rules, ordinances or other laws, including without limitation the United States Electronic Signatures in Global and National Commerce Act, P.L. 106-229 (the "E-Sign Act") or other similar statutes, YOU HEREBY AGREE TO THE USE OF ELECTRONIC SIGNATURES, CONTRACTS, ORDERS AND OTHER RECORDS AND TO ELECTRONIC DELIVERY OF NOTICES, Further, you hereby waive any rights or requirements under any statutes, regulations, rules, ordinances or other laws in any jurisdiction which require an original signature or delivery or retention of non-electronic records, or to payments or the granting of credits by other than electronic means.*

I agreeI disagree
Participant Signature*

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Minor Registration
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Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Minor Liability Waiver and Release Form
I hereby acknowledge and fully understand the potential dangers incidental to engaging in dance, fitness and/or exercise activities, and acknowledge and understand that such activities require physical effort and exertion. I further acknowledge and agree that: 1. I am responsible for consulting my or the minor I present physician or other health care provider prior to enrolling and participating in a dance, fitness and/or exercise activity to determine whether participating in the activity is appropriate for me or the minor I represent. 2. I nor the minor I represent will not enroll in or participate in dance, fitness and/or exercise activity if my or the minor I represent physician or health care provider advises against it. 3. If I or the minor I represent experience faintness, dizziness, pain or shortness of breath at any time during the dance, fitness and/or exercise activity that I or the minor I represent will stop immediately and contact my or the minor's physician or health care provider.*

I agreeI disagreeN/A- No minors participating
I and/or the minor I represent acknowledge and understand that our participation in a dance, fitness and/or exercise activity could result in my exposure to bodily injury, illness, loss or death, as well as property losses and/or damage to property. For and in consideration of NCNW MAC permitting me to enroll and participate in the dance, fitness and/or exercise activities, and in recognition of the possible dangers to which I and/or the minor I represent voluntarily subject myself by participating in the dance, fitness and/or exercise activities and related activities, I and/or the minor I represent HEREBY AGREE AS FOLLOWS: 1. I hereby voluntarily for myself, my spouse, assignees, heirs, guardians or personal representatives, from the date of entry into this Waiver and Release, hold NCNW MAC and the Instructors teaching the dance, fitness and/or exercise activity I enroll and participate in, as well as their agents, employees, officers, directors, spouses, assignees, heirs, guardians or personal representatives blameless and waive any and all rights and causes of action and associated costs for any accident, injury, illness or death, occasioned by my participation in the dance, fitness and/or exercise. 2. In the event I am or the minor I represent is injured, I voluntarily agree to assume any financial obligation, either through personal health insurance, or through some other means, for any medical costs which I incur and NCNW MAC and the Instructors teaching the dance, fitness and/or exercise activities assumes no responsibility for any medical expenses, injury, or personal damage suffered by me in connection with the use of any facilities or services in connection with the NCNW MAC or the dance, fitness and/or exercise activities. 3.I and the minor I represent hereby voluntarily assume all risk of damage or loss to my property while participating in the dance, fitness and/or exercise activities and relieve NCNW MAC and the Instructors teaching the dance, fitness and/or exercise activities from liability for any and all property damage or loss. 4.I acknowledge and agree that by signing up the NCNW MAC Health and Wellness Event, I am submitting a legally binding electronic signature and are entering into a legally binding contract. I acknowledge that the electronic submission constitutes my agreement and intent to be bound by these terms. Pursuant to any applicable statutes, regulations, rules, ordinances or other laws, including without limitation the United States Electronic Signatures in Global and National Commerce Act, P.L. 106-229 (the "E-Sign Act") or other similar statutes, YOU HEREBY AGREE TO THE USE OF ELECTRONIC SIGNATURES, CONTRACTS, ORDERS AND OTHER RECORDS AND TO ELECTRONIC DELIVERY OF NOTICES, Further, you hereby waive any rights or requirements under any statutes, regulations, rules, ordinances or other laws in any jurisdiction which require an original signature or delivery or retention of non-electronic records, or to payments or the granting of credits by other than electronic means*

I agreeI disagreeNA- No minors participating
Participant Signature*

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Minor Child Registration
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Health & Wellness Event

Stomping Out Diabetes

Participant Information

Event Liability Waiver and Release Form

Minor Registration

Minor Liability Waiver and Release Form