MBF Kids Pre-Class Assessment, Release & Emergency Consent

MBF Kids Pre-Class Assessment, Release & Emergency Consent

Complete this before your child’s first MBF Kids class—review safety and consent details, then sign to confirm accuracy.
Child & Parent/Guardian Information
Child's Full Name

First NameMiddle NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Age
Parent/Guardian Full Name

First NameMiddle NameLast Name
Relationship to Child
Email Address
example@example.com
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Enrollment Eligibility & Program Acknowledgements
I confirm my child is at least 6 years old.
I understand MBF Kids is an eight-session program for $200, classes meet on Saturdays at 8:00 AM in Florence, Arizona, and enrollment starts on a rolling basis.
I understand enrollment is limited to 8 children and space is not guaranteed.
I confirm that the information I provided on this form is true, complete, and accurate.
I understand this form may be used to determine whether my child can participate safely.
Child Health, Safety, and Participation Information
Does the child have any medical conditions that could affect participation?
If yes, please describe the medical condition(s) and any care instructions.
Does the child have any recent or recurring injuries or physical limitations?
If yes, please describe the injury or physical limitation and any activity restrictions.
Does the child have any allergies or sensitivities we should know about?

Other
Please list the allergy(s), typical reaction, and any precautions required.
Please list any medications relevant to participation or emergency care, and note when they are taken.
Describe any physical, behavioral, developmental, or sensory considerations that may help us support the child safely.
Are there any other safety concerns we should be aware of?
If yes, please describe any additional safety concerns or instructions.
Emergency Contacts & Medical Response Authorization
Emergency Contact Name

First NameMiddle NameLast Name
Relationship to Child
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If I cannot be reached, do I authorize Mom Bod Fitness/MBF Kids to contact emergency services and the emergency contact(s) listed above?
If emergency medical care is needed and I cannot be reached, do I authorize Mom Bod Fitness/MBF Kids to seek reasonable emergency medical treatment for my child until I can be contacted?
Photo/Video and Communication Permissions
Photo and video permission for program communications (optional)
Permission to use child’s image for marketing or public materials (optional)
Preferred communication methods for program updates and safety notices
Release, Assumption of Risk, and Signature
Release and Assumption of Risk Statement
I acknowledge and agree

I understand that children’s movement and fitness activities involve inherent risks, including falls, collisions, overexertion, and other injuries; I agree to follow all instructions, safety rules, and staff directions; I understand this release is intended to be interpreted in plain language under Arizona law; I understand this release does not waive claims arising from gross negligence, reckless conduct, intentional misconduct, or other non-waivable rights
Typed Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Authorized phone number for text message updates
Should be Empty:

MBF Kids Pre-Class Assessment, Release & Emergency Consent

Child & Parent/Guardian Information

Enrollment Eligibility & Program Acknowledgements

Child Health, Safety, and Participation Information

Emergency Contacts & Medical Response Authorization

Photo/Video and Communication Permissions

Release, Assumption of Risk, and Signature