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This waiver/liability form is standard practice and required prior to beginning classes with Jennifer Gutierrez at SCP Chiropractic and ANY other location in which classes may be held. By signing this consent form, you agree you are in good physical health and able to perform the movements and activities in the classes in full or with reasonable modifications as needed. Waiver and liability release documents are included as well.

We will need contact information including at least one emergency contact.


WAIVER & RELEASE FORM


Because physical exercise can be strenuous and subject to risk of serious injury, we urge you to obtain a
physical examination from a doctor before using any exercise equipment or participating in any exercise activity.

You agree that by participating in physical exercise or training activities, you do so entirely
at your own risk. Any recommendation for changes in diet including the use of food supplements,
weight reduction and/or body building enhancement products are entirely your responsibility and you
should consult a physician prior to undergoing any dietary or food supplement changes. You agree that
you are voluntarily participating in these activities and use of these facilities and premises and assume
all risks of injury, illness, or death. We are also not responsible for any loss of your personal property.
You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a
release of liability. You expressly agree to release and discharge the trainer or instructor from any and
all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise
have to bring a legal action against the trainer or instructor for personal injury or property damage.
To the extent that statute or case law does not prohibit releases for negligence, this release is also for
negligence.
If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be
invalid, then the remainder of this release from liability shall remain in full force and effect and the
offending provision or provisions severed here from.
By signing this release, I acknowledge that I understand its content and that this release cannot be
modified orally.


ACKNOWLEDGMENT OF HEALTH

I declare myself physically and mentally sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in training sessions, group fitness classes, or use of Equipment (as identified below). I have been informed for the need for a physician's approval for my participation, in an exercise/fitness activity or in the use of Equipment. I recognize it is my sole responsibility to obtain an examination by a physician prior to involvement in any exercise program. I acknowledge I have either had a physical examination and have been given my physician's permission to participate, or if I have chosen not to obtain a physician's permission prior to beginning this exercise program with a trainer or group fitness instructor, I acknowledge I am doing so at my own risk. From herein, trainer, instructor, and group fitness instructor are interchangeable in this document.


EQUIPMENT

Trainer/Group Fitness Instructor or I will provide the equipment or machinery to be used in connection with workouts, including but not limited to benches, dumbbells, barbells, resistance bands, kettlebells, and similar items ("Equipment"), and I will have control over the area in which we perform our workouts. I represent and warrant any and all Equipment I provide for training and workout sessions is for personal use only Instructor has not inspected my equipment and has no knowledge of its condition. I understand and I take sole responsibility for My Equipment. I acknowledge that although the Instructor takes precautions to maintain the Equipment provided by Instructor (Her Equipment), Her Equipment or My Equipment may malfunction and/or cause Injuries and Changes (as defined below) and that I take sole responsibility to inspect any and all of Her or My Equipment. Furthermore, I take sole responsibility for any Injuries or Changes Instructor sustains while using My Equipment to demonstrate an Activity, or otherwise, and agree to indemnify her for any and all medical expenses and lost wages related to her use of my equipment.


ASSUMPTION OF RISK

I understand and am aware that Activities, including the use of Equipment, are potentially hazardous activities. I acknowledge the possibility that injuries and physical and mental changes ("Injuries and Changes") arising during and/or resulting from engaging in Activities does exist. Injuries and Changes included but are not limited to abnormal blood pressure, fainting, disorders in heartbeat, heart attack, heat exhaustion, and in some instances, death. I understand Injuries and Changes could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I am voluntarily participating in Activities using Equipment with knowledge of dangers involved. I understand and take sole responsibility for any and all Injuries and Changes that may occur to myself and/or others, including but not limited to Instructor, related to any and all Activities associated with Instructor's training, instruction, workout plan, even if not specifically set forth in this document, whether or not they fall within the scope of reasonably foreseeable injuries related to such Activities, and whether or not undertaken in Instructor's presence. Although Instructor will take precautions to ensure my safety. I expressly assume and accept sole responsibility for my safety and for any and all Injuries and Changes that may occur.

 

WAIVER AND RELEASE OF LIABILITY

In consideration of Instructor's agreement to instruct, assist, and train me, I hereby agree to hold harmless Instructor, its respective representatives, instructor substitutes, executors, agents, and assigns, owner and leaser of facility in which classes or training are held, from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected to my participation in any and all Activities, use of Equipment, or any and all acts of omissions, including negligence by Instructor(s) and his/her representatives. This waiver and release of liability includes, but is not limited to, (a) Injuries and Changes to myself and/or others, including but not limited to Trainer, that may occur as a result of (i) Equipment that may malfunction or break; (ii) any and all defects, latent or apparent, in the design or condition or Equipment; (iii) any and all slips, falls, or dropping of Equipment; (iv) any and all improper maintenance of Equipment or facilities; (v) any hazardous condition that may exist on the premises, including but not limited to, the specific workout area; and (vi) Instructor's negligent instruction or supervision; (b) damage to property, including but not limited to, Equipment and the premises.

Any suggestions for modifications to increase or decrease intensity or adjust for personal mobility limitations, etc, are accepted upon your discretion.

Nutritional advice. I am a Certified Fitness Nutrition Specialist and PN 1 Nutrition Coach. I can offer guidance and coaching within my scope of work. You may elect to use my services at our agreed-upon terms. While I do my best and stay up to date with current science, nutrition information and training, I cannot guarantee results. We will work together to devise a plan we mutually feel is a good fit and may need to modify as we progress in the coaching plan. A separate agreement and waiver may be applicable if I am hired on as your nutrition coach.


CONCLUSION

I acknowledge and agree no warranties or representations have been made to me regarding the results I will achieve from this program and/or fitness classes. I understand results are individual and may vary. 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 a physical activity. Having such knowledge, I hereby acknowledge this release, any 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 which may affect my ability to participate in said fitness program.

I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims against Instructor, its respective representatives, executors and/or assigns.

I represent and warrant I am signing this agreement freely and willfully and not under fraud or duress. I further represent and warrant no social relationship exists between Instructor and me, or if such a social relationship exists, for purposes of my training sessions, Instructor and I have assumed a strict business relationship, and I understand any social relationship does not render this waiver invalid. These exculpatory clauses are intended to apply to any and all activities occurring during the time which I have contracted with Instructor.


 

CANCELLATION/REFUND POLICY

Refunds are at the discrection of the Instructor. Classes are limited to the number of participants per class due to the equipment and/or space limitations. If a participant reserves a spot in class and does not show up, this prevents another participant from attending class. If a participant does not cancel within the designated timeframe to avoid a cancellation fee or is a no-show to class, cancellation fees up to the amount of the per-class rate are due. I agree I am responsible for payments for classes I attend as well as cancellation fees as they apply.

Classes are non-transferrable to any other individual.

MINORS

Participants under 18 must have a parent or guardian sign this document. If a parent/guardian chooses not to attend or observe class while minor is participating, parent/guardian affirms the minor is in good physical condition to perform activities and has explained to minor that he or she has the right to opt out of any activity he or she is not comfortable performing. Minor may also choose modifications as needed, as with any other participant. It is encouraged that parent/guardian be present for at least 1-2 classes if possible. Parent must ensure minor particpant has adequate water/hydration, wears the appropriate clothing and shoes for the activity and is able and willing to follow instructions from class instructor/trainer.

 

 

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Participant's 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
Check to receive information, news, schedule/class updated and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Do you have any movement limitations, joint or muscular issues, etc that may require modifications in exercises?
Click to customize text box label
What do you hope to achieve with your exercise regimen?
Select one or more
Weight Loss
General Health and Wellness
Tone up
Maintain Weight
Have fun
Other
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Relationship*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic 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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