Consent, Waiver Release Of Liability (Page 2 of 2) in pdf

Consent, Waiver Release Of Liability Page 2

THIS AGREEMENT CONSTITUTES THE ENTIRE AGREEMENT BETWEEN THE PARTIES REGARDING THE SUBJECT

MATTER HEREIN, AND IS GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF

CALIFORNIA.

TO BE COMPLETED BY CLIENTS AGE 18 AND OVER

BY SIGNING BELOW, I ACKNOWLEDGE I’VE READ AND UNDERSTAND THE TERMS OF THIS CONSENT,

WAIVER & RELEASE OF LIABILITY

Name of Client (Please Print)

Date

Signature of Client

Phone number

Address

TO BE COMPLETED ON BEHALF OF MINOR CLIENTS UNDER THE AGE OF 18

BY SIGNING BELOW, I ACKNOWLEDGE I’VE READ AND UNDERSTAND THE TERMS OF THIS CONSENT,

WAIVER & RELEASE OF LIABILITY

Name of Minor Client (Please Print)

Date

Age of Minor Client

Date of Birth of Minor Client

Name of Parent or Legal Guardian to Minor Client (Please Print)

Signature of Parent or Legal Guardian

Relationship to Minor Client

EMERGENCY CONTACT INFORMATION

Name

Home Phone

Relationship

Employer

Work Phone

Cell Phone

INSURANCE INFORMATION (In case of emergency only)

Primary Doctor/Group Name

Phone

Primary Insurance Carrier

Phone

Group ID _____________________________

Member ID

NextStep Fitness, Inc.

Page 2 of 2

NEXTSTEP Liability Release Final.doc

Consent, Waiver Release Of Liability Page 2