Workout with Callie
Please fill out this form if you are interested in enrolling in the fitness program with Callie. Payment by check or cash (make sure it is in an envelope with your information) is required the first class date. If you need special accommodations on when you pay, please contact us. Thanks for taking the time to fill this out!
Email address *
Participant Name *
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Phone Number *
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Participant's name
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Participant's name
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Participant's name
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Participant's name
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Participant's name
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Payment is due the first class (monthly) or other dates agreed upon through prior communication. I understand that my enrollment is dependent on this payment. *
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RELEASE OF LIABILITY- READ BEFORE SIGNINGIn consideration of being allowed to participate in any way in the Douglass Recreation program, its related events and activities, I __________________________, the undersigned, acknowledge, appreciate, and agree that : 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the company immediately; and, 4. I for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE , IDEMNIFY, AND HOLD HARMLESS THE DOUGLASS RECREATION COMMISSION, their officers, officials, agents, and / or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used for the activity (“ Re-leasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARRISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. X__________________________________ AGE_________ DATE SIGNED_________ (Participant’s Signature ) FOR PARENTS / GUARDIANS OF PARTICIPANTS OF MINORITY AGE ( Under Age 18 at time of registration ) This is to certify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above for all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARRISING FROM THE NEGLEGENCE OF THE RELEASEES, to the fullest extent permitted by law. X_____________________________ ______________________ DATE____________ (Parent/ guardian signiture) (Minors Name) *
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