Waiver

Yvonne’s Fitness Waiver Form

First Name

Last Name

Age

Phone #

I consent to receiving e-mail regarding Zumba & Fitness activities with Yvonne’s Fitness.

Yes

Emergency Contact Name

Emergency Contact Phone #

All participants are required to read and fill in the form, answering in truth in order to register and participate in any of the Zumba/Yoga classes at LWCC. Once completed, submit with full payment to Yvonne’s Fitness.

PAR-Q & YOU: Please check the appropriate answer:

1. Has your doctor ever said that you have heart condition and that you should only do physical activity recommended by a doctor?

Yes

2. Do you feel pain in your chest when you do physical activity?

Yes

3. In the past month, have you had chest pain when you were not doing physical activity?

Yes

4. Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes

5. Do you have a bone of joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?

Yes

6. Is your Doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes

7. Do you know of any other reason why you should not do physical activity?

Yes

***If you checked “YES” to any of the questions above, you will require your doctor’s approval before participating***

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY FOR ZUMBA/YOGA/FITNESS CLASSES

(herein referred to as the participant)

(Print YOUR name)

I, the above named participant, hereby agree to the following:

1. I am participating in classes taught by the authorized ZUMBA /YOGA/FITNESS instructor or licensed substitute. I recognize that the classes may involve strenuous physical activity including, but not limited to, cardiovascular conditioning and interval training, muscle strength and endurance training, and other various fitness activities that may cause physical injury, and I am fully a ware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regardi ng my participation in the ZUMBA/YOGA classes. I represent and warrant that I am in good physical condition and do not suffer from any known disability or medical condition which would prevent or limit my participation in this exercise program.

3. In consideration of being permitted to participate in ZUMBA/YOGA classes, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as result of participating in the program.

4. In consideration of being permitted to participate in ZUMBA/YOGA classes, I knowingly, voluntarily and expressly waive any claim I may have against licensed instructor for injury or damages that I may sustain as a result of participating in the program.

5. I, my heirs or legal representatives forever release, discharge and covenant not to sue licensed instructor for any injury of death caused by their negligence or other acts.

I HAVE READ THE ABOVE RELEASE AND WAIVER OF LIABILITY AND FULLY UNDERSTAND ITS CONTENTS. I VOLUNTARILY AGREE TO THE TERMS AND CONDITIONS STATED ABOVE.

(IF PARTICIPANT IS UNDER 18), AS LEGAL GUARDIAN OF

, I CONSENT TO THE ABOVE TERMS AND CONDITIONS.

SIGNATURE OF PARTICIPANT OR GUARDIAN

DATE