Pole Control Studios Waiver

of Liability
First name___________________________ Last name_______________________________

Address_________________ City _______________State_________ Zip Code_________

Date Of Birth____/_____/19______ How “Young are You?”

Occupation( for professional use only)___________________________________

Home Phone (________)_______________-______________________

Mobile Number(_______)___________________________________

Email Address____________________________________________@______________________.com

Emergency Contact Full Name______________________________________ Relationship____________________________

Emergency Contact Phone_____________________________________

I_______________________________________ Acknowledge the above information is true and correct I have read
(Print Full Name)
and accept the terms, conditions, class policies, and the confidentiality and non-disclosure policy, of Pole Control Studios. I
understand the rules and dangers of using the pole. I waive and release any and all claims whatsoever arising from my participation in
Pole Control Studios fitness classes or my participation in demonstrations given at workshops parties events or trade shows.
We use the above information for newsletters and important messages to you. We do not share this information with any third
party.
Signature_______________________________________ Date____________________________________

Pole Control Studios Waiver

of Liability
First name___________________________ Last name_______________________________

Address_________________ City _______________State_________ Zip Code_________

Date Of Birth____/_____/19______ How “Young are You?”

Occupation( for professional use only)___________________________________

Home Phone (________)_______________-______________________

Mobile Number(_______)___________________________________

Email Address____________________________________________@______________________.com

Emergency Contact Full Name______________________________________ Relationship____________________________

Emergency Contact Phone_____________________________________

I_______________________________________ Acknowledge the above information is true and correct I have read
(Print Full Name)
and accept the terms, conditions, class policies, and the confidentiality and non-disclosure policy, of Pole Control Studios. I
understand the rules and dangers of using the pole. I waive and release any and all claims whatsoever arising from my participation in
Pole Control Studios fitness classes or my participation in demonstrations given at workshops parties events or trade shows.
We use the above information for newsletters and important messages to you. We do not share this information with any third
party.
Signature_______________________________________ Date____________________________________