Youth Training Release Form
Sign in to Google to save your progress. Learn more
Email *
Full Name *
First and Last Name
Date of Birth *
MM
/
DD
/
YYYY
Age *
Parent's Name *
First and Last Name
Address *
Street Address / City / State / Zip
Phone number *
(XXX) XXX-XXXX
Emergency Contact Info
Contact Name *
First and Last Name
Contact Phone *
(XXX) XXX-XXXX
Contact Relationship *
Parent, Family Member, Friend, etc.
Release of Liability Waiver
In consideration of gaining access to participation in activities with Empower Personalized Fitness, LLC, facilities, equipment, and machinery, I do hereby waive, release, and forever discharge Empower Personalized Fitness, LLC, its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in said program.

In consideration of gaining access to participation in activities with Empower Personalized Fitness, LLC, facilities, equipment, and machinery, I do hereby waive, release, and forever discharge Empower Personalized Fitness, LLC, its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in said program.  

I understand the policies and procedures set forth by Empower Personalized Fitness, LLC and have had the opportunity to discuss my specific needs in relation to participatory activity and, as a result, I do voluntarily request the right to participate in this physically active program of exercise.
I do hereby authorize Empower Personalized Fitness, LLC and its staff to utilize any and all photographs, pictures or other likeness of me or anyone assigned guardianship to me, as they deem appropriate in its promotional materials.

Also, in consideration of the above factors, the undersigned participant acknowledges the existence of risks in connection with these activities, assumes such risk and agrees to accept the responsibility for any injuries sustained by the participant during the course of the session or time on the court.  Most specifically, the participant acknowledges and accepts responsibility for injuries arising out of those activities which involve risk in any of the following areas:

• The use of the studio or company equipment
• The performance of fitness related evaluations to assess functional capacity
• The participation in individual or group activities related to exercise, and performance activity
• Incidents which occur in the studio or any other areas associated with Empower Personalized Fitness, LLC

In addition, it is seriously recommended that participants consult with a physician before engaging in any activities associated with Empower Personalized Fitness, LLC.

Having read the preceding, the participant acknowledges full understanding of those risks set forth herein and knowingly agrees to accept full responsibility for the participant’s own exposure to such risks and to waive full responsibility and liability on behalf of Empower Personalized Fitness, LLC.

Child’s Name: *
Full Name
Date *
MM
/
DD
/
YYYY
Parent’s Signature: *
Simple enter your full name.
Client Release of Liability – Covid-19 Addendum
Client and Parents are aware of the current outbreak of the Covid-19 virus (Coronavirus), now classified by the World Health Organization (WHO) as a pandemic, which may pose an adverse impact to clients’ health and safety. In order to participate in the services offered by Empower Personalized Fitness, LLC I agree to the following:

Child will not come to the training/program if they have a fever or have had any of these symptoms for last 10 days:
• Fever of greater than 100.4
• Cough
• Shortness of Breath
• Loss of sense of smell or taste
• Severe headache
• Sore throat

Child will not come to the training/program for 10 days if I test positive for Covid-19.

Child will not come to the training/program if I come in close contact with someone who has been quarantined, tested or diagnosed with Covid-19 in the past 5 days.

Child will maintain social distance as much as possible.

Child will bring a mask to training/program and agree to wear it during any indoor activities as long as it is recommended to do so by local authorities or Empower Personalized Fitness, LLC.

**Close is defined as a) being within approximately 6 feet of a person with Covid-19 (such as caring for or visiting the patient; or sitting within 6 feet of the patient b) being coughed on, touching used tissues, etc.

ACKNOWLEDGEMENT OF TERMS AGREEMENT

I have read the preceding and acknowledge full understanding of its terms and those risks set forth herein and I knowingly agree to accept full responsibility for my own exposure to such risks and to waive full responsibility and liability on behalf of Empower Personalized Fitness, LLC, and its employees.  I understand the policies and procedures set forth by Empower Personalized Fitness, LLC. and have had the opportunity to discuss my specific needs in relation to participatory activity and, as a result, I do knowingly and voluntarily request the right to participate in this preventive program of exercise.  I sign this agreement voluntarily and with full knowledge of its significance.

Parent’s Signature: *
Simple enter your full name.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy