For Every Body Fitness

Registration Informed Consent Waiver

Please note that all fields are required.

Please initial next to each number:

1. I wish to participate in this For Every Body Fitness exercise program or class.

2. I understand this program is intended to improve muscular endurance, flexibility, strength, cardiovascular and respiratory health, body composition, balance and coordination.

3. I understand that participation in this activity involves risks of injury, including, but not limited to: sprains, muscular strains and soreness, fatigue, heat related illness and orthopedic problems or injuries. I also recognize that there are many other serious and disabling injuries and illness which may arise due to my participation and that is not possible to specifically list each injury risk.

4. I understand it is advisable, and For Every Body Fitness recommends that you consult your physician prior to participation in this program and class. Please present written consent from your physician if you have or have had any of the conditions listed below, or experience any change in condition(s) or medications you have listed.

• Heart or Respiratory Disease
• Recent Surgery or Miscarriage
• High Blood Cholesterol (200+)
• High Blood Pressure
• Overweight (+20)
• Pregnancy (Doctors note required)
• Muscle Joint or Back Disorders
• Diabetes

ALL PERSONS OVER 35 YEARS WHO HAVE NOT EXERCISED IN A YEAR OR MORE SHOULD HAVE A FULL MEDICAL EXAM INCLUDING EKG PRIOR TO BEGINNING THIS OR ANY OTHER EXERCISE PROGRAM

5. I have had the opportunity to ask questions and they have been answered to my complete satisfaction. I completely understand the risk of my participation in this activity and knowing and understanding these risks, I voluntarily choose to assume all risks or injury, illness and even death due to my participation in this activity.

6. I the undersigned and my beneficiaries hereby release, discharge and hold harmless For Every Body Fitness, its parent company, Shari’s Body Works, Inc., its Board of Directors, Staff, Instructors, and all affiliated entities from any and all claims, demands, damages, actions, or causes of action.

Signature (Full name):

Date:

Witness (Full name):

Date

Getting to Know You

Name:

E-mail:

Home Phone:

Work Phone:

Address:

DOB: (mm/dd/yy)

Location of the classes you are attending:

Please list any medical conditions:

Please list any medications you are currently taking:

Please list any major surgery or orthopedic surgeries:

Are you pregnant? No Yes
(If you are pregnant a doctors note is required)

Are you currently trying to reduce your weight?
No Yes

Is your weight loss program supervised by a physician?
No Yes n/a - not trying to reduce weight

Emergency Contact:

Emergency Contact Phone:

Please initial and date:

I attest that the above information is true and correct

Date:

All information listed above will remain confidential.

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