Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

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Cell Phone

(###)

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I am interested in the following activities:

Personal Training

Group Training

Youth Fitness

Spin Class

Boot Camp

Nutrition/ Weight Loss

Other

WAIVER AND RELEASE OF LIABILITY *

I, ______________________________________________, acknowledge that I have been advised to consult with a physician prior to participating in any exercise sessions, programs, and/or classes (hereinafter referred to as “Exercise”) offered by Thomas Moreland Fitness, LLC (hereinafter referred to as TMF, LLC). I acknowledge that my doctor has advised that I may participate in exercise. If I have not been so advised, I acknowledge that I am participating at my own risk. I acknowledge that I have no disability, impairment or ailment preventing me from engaging in Exercise that would be detrimental to my health, safety, or physical condition. I hereby warrant that any information I have given to TMF, LLC, with regard to my health and physical condition is complete and accurate. I hereby agree to report to TMF, LLC, immediately, any conditions, defects, injuries, pregnancy, etc. upon such change. I acknowledge and agree (1) that TMF, LLC, will rely on the foregoing warranty in allowing me to participate in Exercise; (2) that TMF, LLC, shall have no obligation to perform a fitness assessment or similar testing to determine my physical condition; (3) that if any fitness assessment or similar testing is performed by TMF, LLC, it is solely for the purpose of providing comparative data with which I can chart my progress regarding Exercise, and is not for diagnostic purposes; (4) that TMF, LLC’s personnel have no expertise in diagnosing examining, or treating medical conditions of any kind or in determining the effect of any specific Exercise on said medical condition. I fully understand and agree that in participating in Exercise or using the facilities maintained by TMF, LLC there is the possibility of accidental or other physical injury. I agree to assume the risk of such injury and further agree on behalf of myself and my executors, etc. to release and discharge TMF, LLC, its affiliates, employees, agents, independent contractors, representatives, officers, directors, successors and assigns from all claims or causes of action arising out of TMF, LLC’s negligence. This Waiver and Release of Liability includes, without limitation, injuries which may occur as a result of (a) my use or any exercise equipment or facilities which may malfunction or break (b) TMF, LLC’s improper maintenance of any exercise equipment of facilities, (c) TMF, LLC’s negligent instruction or supervision, and (d) my slipping or falling while in the facility or on the premises. I acknowledge that I have carefully read this Waiver and Release of Liability and fully understand that it is a release of liability. I am waiving any right that I may have to bring a legal action to assert a claim against TMF, LLC its affiliates, employees, agents, independent contractors, representatives, officers, directors, successors and assigns for their negligence. I acknowledge that TMF, LLC, is not responsible for the loss of, or damage, any personal property belonging to me while I am on the premises of TMF, LLC. PARTICIPANT SIGNATURE: _______________________________________________ DATE: ________________________

I have read and agree to the waiver.

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First Name

Last Name

Date Waiver and Release of Liability signed *

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DD

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