Loading...

Waiver and Release Agreement

As the student involved in SummaMobility's training, I understand that training with SummaMobility includes physical movements and exertion. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I understand that it is my responsibility to consult with a physician prior to and regarding my participation with SummaMobility, whether in-person or online. I represent and warrant that I am in good health and physical condition and I have no medical condition which would prevent my full participation in training, whether in-person or online. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature below verifies that I have my physician’s approval to participate. In consideration of being permitted to participate in SummaMobility's training, whether in-person or online, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program. In further consideration of being permitted to participate in SummaMobility's training, whether in-person or online, I expressly irrevocably release and waive any claims that I have now or may have hereafter for any reason against SummaMobility for injury or damages that I may sustain as a result of participating in a SummaMobility's training, whether in-person or online.

 

Cancellation:

When cancelling an appointment, I am required to provide MORE than 24-hour notice, for which no additional levy shall be incurred. However, if I cancel a session LESS than 24 hours to the scheduled time, I shall be charged in full for that training session, while my therapist will utilize that time in working on my fitness program. I understand that I’m entitled to a one-time cancellation fee waiver per (4 session package) with no penalty.

 

Media

I may be photographed while at the studio and these photographs may appear in SummaMobility's promotional materials unless otherwise specified. No person whose photograph is used will be identified by name, nor will any compensation be extended for such use unless otherwise specified.



First Clients Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Clients Date of Birth*
Date of Birth
First Clients Signature*
Second Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Third Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Fourth Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Fifth Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Sixth Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Seventh Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Eighth Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Ninth Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Tenth Clients Name
First Name*
Middle Name
Last Name*
Select Gender
Clients Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Summa Screening Form
Do you have any known disease or local infection at the present time?*
No
Yes
Do you have any heart or lung conditions?*
No
Yes
Do you have a history of osteoporosis, osteopenia, or "brittle bones"?*
No
Yes
Do you have any history of surgery?*
No
Yes
Do you have any implants - ie. Cardiac Pacemaker, Total Joint Replacement...?*
No
Yes
Do you have any history of fractures?*
No
Yes
Do you have any muscle, tendon, ligament, skin, or other soft-tissue damage?*
No
Yes
Do you have any significant muscle weakness in your arms or legs?*
No
Yes
Do you have any bowel or bladder issues?*
No
Yes
Do you have any history of cancer or metastatic bone disease?*
No
Yes
Do you have any areas of decreased or absent sensation?*
No
Yes
Do you have any artery of vein conditions?*
No
Yes
Do you have any conditions that may increase risk of bleeding or bruising?*
No
Yes
Do you have any neurological conditions?*
No
Yes
Are you pregnant or actively trying for pregnancy?*
No
Yes
*If you answered yes to any of the questions above, please consult with your practitioner regarding possible health risks which may limit your participation in Body Tempering.
Please list any other past medical or orthopedic history:


Click to customize text box label
Please list any medications that you are presently taking (if any):
Click to customize text box label
Emergency Contact
Click to customize text box label
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*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By signing this document, I hereby release any of the SummaMobility Instructors and Body Tempering Certified personnel from all liability. 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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!