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Extreme Results by Vince

Release of Liability & Indemnity Agreement

In consideration of being permitted to participate in an exercise/conditioning work-out program, conducted by Vincent Ceniceros, or any
independent trainer, (herein referred to as trainer/s), or any other representative and/or agent of Extreme Results (herein referred to as Extreme Results)
the client, and their personal representatives, heirs, and next of kin, releases, waives, discharges and covenants not to sue
trainer/s or his personal representatives, assigns, heirs, and next of kin for any/all loss or damage, and any claim or damage, on the account of
injury to the person or property, or death of the client, whether caused by the negligence of releasees or otherwise, while the client is engaging
in the activity described above. Client acknowledges the risk of engaging in such vigorous exercise and physical activity and hereby
represents they are fully capable of doing so of their own free will.

Client acknowledges and fully understands that they will be engaging in activities that involve risk of serious injury, which may include
permanent disability and even death, and severe social and economic losses which might result not only from their own actions, but also from
the action, inaction or negligence of others, the rules of play, or the condition of the premises, or any equipment used, and further that there
may be risks not known to them or not reasonably foreseeable. Client expressly assumes all risks of injury, including death, which may occur
in connection with participation in activities at
Extreme Results.

Client consents to emergency medical care and transportation in order to obtain treatment in the event of injury as any respective agents,
representatives, affiliates, associates, officers, directors, and/or employees of
Extreme Results
deem appropriate. This release extends to
any liability arising out of or in any way connected with the medical treatment and transportation provided in the event of an emergency.

Client expressly agrees that the terms of release and indemnity contained herein are intended to be as broad and inclusive as is permitted by
the laws of the state of Ohio. Any provision or portion of this Waiver, Release, and Indemnity Agreement found to be invalid by the courts
having jurisdiction shall be invalid only with respect to such provision or portion. The offending provision or portion shall be construed to the
maximum extent possible to confer upon the parties the benefits intended thereby. Said provision or portion, as well as the remaining
provisions or portion hereof, shall be construed and enforced to the same effect as if such offending provision or portion thereof had not been
contained herein. Any representative of
Extreme Results
reserves the right to refuse service to anyone for any reason; refund is not
guaranteed.

PERSONAL TRAINING SESSIONS
All monies paid for personal training sessions, either package or individual sessions are
nonrefundable, and must be paid in full prior to scheduling initial session.
Customer will be charged full price of missed session without
24-hour notice of cancellation. If customer fails to schedule and complete all sessions as previously agreed within 90 days, any and
all monies remaining shall be forfeited to trainer as liquidated damages.

 

Please select who will be participating in class or training
AdultMinor
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First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
Don't Miss Extreme Results Discounts !!
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Release Of Liability & Indemnity Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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