Scheduling Form

1

Program of Interest* This field is required.

2

Schedule SessionPlease select the time that best fits with your schedule and based on availability we will be in touch to confirm your session

3

Name* This field is required.

First Name

Last Name

4

Age? Prior Injuries/Medical Conditions we should be aware of?* This field is required.

5

Phone Number* This field is required.

Please enter a valid phone number.

6

Email* This field is required.

example@example.com

7

SignatureRELEASE FOR USE OF NAME, IMAGE, and LIKENESS: I understand Premier Performance Institute may take or receive photographs, video, audiotape and other image and sound-based media of its facilities, including its employees, athletes, and other visitors. Premier Performance Institute may wish to use such photographs for educational, promotional, advertising, and other purposes. This permission for release, without compensation or prior notice, would allow Premier Performance Institute to use photographs in its printed publications, during presentations, and otherwise. Therefore, I hereby freely and voluntarily consent to the use and publication of my name, participation, picture, or likeness by Premier Performance Institute or its employees or agents for any and all purposes including, but not limited to, educational, promotional, advertising, and trade, through any medium or format, including, but not limited to, videotape, audiotape, film, photograph, television, radio, digital, internet, theater, or exhibition, at any time from this date forward until I revoke this consent in writing. I further waive any claims against Premier Performance Institute, its employees, or agents based upon or related to its use or publication of my likeness, voice, participation, or picture. I freely give this authorization without expectation of compensation.

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