What is Movement Waiver & Health Information.

22 Dewey Ave, Unit 7, Warwick Rhode Island 02886.

Name: __________________________________

Email: __________________________________

 Address: _______________________________________

City, State, Zip: ______________________________________________________

Date of Birth: ______________________

Home Ph # : ______________________

Cell Ph # : ________________________________

In an emergency, I would like What Is Movement to Call:

Name and Phone # ___________________________________ _____________________________________________________

Health Questions Do you: Smoke? Y N        Drink alcohol? Y N

Take prescription meds? Y N____________________       

 Are you exercising now? Y N

How much per week? _______

Do you play sports? Y N_________________

Do you have: Back pain, Knee pain or Shoulder pain? Y N______________

Previous Injuries or Surgeries? Y N_______________________     

High blood pressure, Asthma, Diabetes, or a Heart condition? Y N

Any other health conditions not listed? Y N _____________________________________________________________________________________________________________________________

Reviewer Notes: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Photography/Video Release

Participants involved in any activities offered by What i s Movement  may be photographed or videotaped during training. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the What is Movement  website or in any editorial, promotional or advertising material produced and/or published by What is Movement.      Initials: ________

Waiver and Release of Liability Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. These risks include, but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, my training partner, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under direction of What is Movement. I acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others.  Initials:_________  

Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by What is Movement, I, the undersigned hereby release What is Movement, their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect. If I am signing on behalf of a minor child, I also give full permission for any person connected with What is Movement to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child. Indemnification: The participant recognizes that there is risk involved in the types of activities offered by What is Movement. Therefore the participant accepts financial responsibility for any injury that the participant may cause either to him/herself or to any other participant due to his/her negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless What is Movement, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by What is Movement, at the main building or abroad. This includes but is not limited to parks, recreational areas, playgrounds, areas adjacent to main building, and/or any area selected for training by What is Movement. I have read and understood the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.

Signature of participant:_________________________________

Date: _____________

If the participant is under the age of 18, Signature of Parent/Guardian: __________________________________

Print Name: __________________________________

Date: ______________

 Reviewed By (Print): _______________________________

Signature: ___________________________________

Date: ___________________