WAIVER OF LIABILITY  

Personal Information:

Name: _______________________________ Date of Birth: ____/____/____

Address: _____________________________ Phone: ___________________

City/State/Zip: __________________________________________________

Emergency Contact Person: ______________________________________

Emergency phone: _____________________

Relationship to emergency contact: ____________________

Email:  _______________________________________________

Can photos be taken of your child for website or marketing materials?  _____Yes  _____No

Liability Waiver:

I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity.

Having such knowledge, I hereby release Christi Smith/Pro-Motion Sports, their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity.  I hereby assume all risks connected therewith and consent to participate in said program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program.

Signature: ____________________________________________

Date: ___/___/___