WAIVER | Athletic Society

Gym & Fitness Liability Waiver

First name

Last name

DOB

Phone

Emergency contact first name

Emergency contact last name

Emergency contact phone

Please specify anything we should know about

Do you have a doctor’s permit to participate in intense physical activities?

Yes

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I acknowledge and agree that Athletic Society, Bend and their employees are not a medical professional and do not provide any medical diagnoses or treatments. I agree that if I have any medical condition, I will seek the help of a medical professional

I declare that the info I’ve provided is accurate & complete

Your Signature

Thanks for submitting!