Please Complete Both Sides.

Registrant Details:
First Name:

Last Name:

Address:

Male / Female

City/State:

Email:

Zip: .

Phone:

Birthday:

Emergency Contact and Telephone Number:

Name:

Phone:

How did you hear about us?

_____ Friend
_____ Google
_____ Ad
_____ TV
Other: ___________________________________________________________________________________________
Have you participated in the following:
Yoga
Pilates
group classes

running

weight training

Other: .
Are you currently experiencing any of the following conditions?

Asthma





Pregnancy
how

High Blood Pressure



Low Blood Pressure

Heart/Circulatory Problems


Muscular Injury

Neck/Back/Spine Injury


Joint Injury

Dizzy Spells/Fainting



Recent Surgery: (specify)

Epilepsy/Seizures



Other condition


Diabetes










Anything you would like us to know: (ie. goals, previous injuries, favorite color?)

far along?

5781 San Felipe Houston, TX 77057 phone: (713)780-7799 fax: (713)780-7798 define@DEFINEbody.com
www.DEFINEbody.com

CONSENT AND WAIVER OF LIABILITY

This form is an important legal document. It explains the risks you are assuming by beginning an exercise program. It is critical that you
read and understand it completely. After you have done so, please print your name legibly and sign in the spaces provided at the bottom.
I, _____________________________, with full knowledge and understanding that participation in the physical activities and fitness training
services offered by Define, LLC (hereinafter Define), involved increased personal injury to me. Such personal injury may result from my
own action or inaction and/or the action or inaction of others.

I understand that Defines exercise classes might be difficult and

strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual
physical changes during exercise does exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart
attack; and in rare instances, death.

Therefore, I assume all responsibility for any of the physical changes that could occur through my

participation in any Define fitness program.

I understand that as a result of my participation in an exercise program, I could suffer an injury or physical disorder that could result in
my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life. I understand
that I should consult a physician prior to beginning any activity program, including Defines exercise classes. I recognize that it is my
responsibility to notify my teacher of any serious illness or injury before every class. I will not perform any postures to the extent of strain
or pain. I do here and forever accept that neither the instructor, owner, or facility is liable for any injury, or damages, to person or
property, resulting from participating in Defines exercise class(es).
I hereby grant permission to Define, and its employees, agents, representatives, licensees and assigns to photograph my image, likeness,
or depiction. I hereby grant permission to Define to edit, crop, or retouch such photographs, and waive any right to inspect the final
photographs. I hereby consent to and permit photographs of me to be used by Define for any purpose, including advertisement purposes,
and in any medium, including print and electronic. I understand that Define may use such photographs with or without associating names
thereto. I further waive any claim for compensation of any kind for Defines use or publication of photographs of me.
I do here and forever release and discharge and herby hold harmless Define and their respective agents, heirs, assigns, contractors, and
employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected
with my participation in this or any exercise program including all injuries resulting from my participation and enrollment in Defines
exercise classes. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF
1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK, 2) ANY SLIP, FALL AND/OR DROPPING OF EQUIPMENT AND 3) ANY NEGLIGENT
INSTRUCTION OR SUPERVISION.
I also fully and forever release and discharge and hold harmless Define from any claim for damages of any kind (including, but not limited
to, invasion of privacy; defamation; false light or misappropriation of name, likeness or image) arising out of the use or publication of
photographs of me by Define, and covenant and agree not to sue or otherwise initiate legal proceedings against Define for such use or
publication on my own behalf. All grants of permission and consent, and all covenants, agreements and understandings contained herein
are irrevocable.
Those under 18 years of age must have this form signed by a parent or guardian.
ACKNOWLEDGEMENT AND UNDERSTANDING:
I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THE ABOVE CONSENT AND WAIVER OF LIABILITY AND FULLY UNDERSTAND ITS TERMS,
INCLUDING UNDERSTANDING THAT I AM GIVING UP SUBSTANTIAL RIGHTS, INCLUDING MY POTENTIAL RIGHT TO SUE. I ACKNOWLEDGE
THAT I AM SIGNING FREELY AND VOLUNTARILY, AND INTEND BY MY SIGNATURE TO COMPLETELY AND UNCONDITIONALLY RELEASE THE
IDENTIFIED PARTIES, INCLUDING ANY EMPLOYEE, AGENT OR CONTRACTOR OF DEFINE, FROM AND OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL
ACTION OR ASSERT A CLAIM.

________________________________________________

_________________

Participants Signature (parent/guardian if under 18)

Date

________________________________________________
Please Print Name