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Tommie Burch LLC

Please read the following carefully. If you have any questions, please have them answered before signing this document. In consideration of and as an inducement to enroll as a participant of Tommie Burch LLC. DBA Balance by Tommie, the undersigned, in full recognition and appreciation of the dangers and risks inherent in such physical activity, does hereby waive, and release any and all claims against Tommie Burch LLC. For any and all damages to my person or property resulting from my enrollment and participation in Tommie Burch LLC activities and will not hold Tommie Burch LLC responsible for the same. I understand and admit that my participation in Tommie Burch LLC activities is voluntary. I recognize and understand that activities may be physically strenuous, that my participation is solely at my own risk, and that I assume full responsibility for any resulting injuries and damages.

I affirm that I am in good physical health and physically capable of participating in Tommie Burch LLC activities. I acknowledge that it is the recommendation of Tommie Burch LLC that I be examined by a licensed physician before enrolling in Tommie Burch LLC activities. I understand that it is my responsibility to verbally notify Tommie Burch LLC of any physical injuries or impairments I have suffered or may currently suffer, as well as any emergency medical information pertinent to my health. 

I affirm that I have not being using alcohol/substances that may impair motor skills prior to taking the fitness class. 

In addition to the foregoing, I hereby acknowledge the following: my paid class fee is non-refundable; that I am to receive instruction in exercise only and will not hold Tommie Burch LLC to any higher standard of care.

I acknowledge that I have read and understand this entire Release and Waiver of Liability. I further acknowledge that I have had the opportunity to review the Release and Waiver of Liability with an attorney of my choosing if I so desire. In light of the foregoing, I agree to be legally bound by this Release and Waiver of Liability. I also understand and acknowledge that this Release and Waiver of Liability also binds my heirs, executors, administrators, and assigns.



First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Emergency Contact
First Name*
Last 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.


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*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
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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