Enrollment Form for Fitness Instructor Insurance

Application, Medical Questionnaire, Release, Waiver of Liability and Indemnity Agreement

with to Study Yoga and/or Cardio Kickboxing

Full Name

Date of Birth

Street Address

City State Zip

Home Phone #

Cell Phone #

Email

I understand that it is my responsibility to consult with a physician prior to and regarding my participating in the Yoga and/or Cardio Kickboxing Classes, Health Programs or Workshops with , and to receive prior approval to participate. I represent and warrant that I am physically fit and I have no medical condition or injury, which would prevent my full participation in the Yoga and/or Cardio Kickboxing Classes, Health Program and Workshops of .

Personal Health History

Have you had any of the following? Respond with a “Y” if yes or a “N” if no in the space indicated. Please answer all questions.

Do you have any allergies? YES NO

If yes, please specify:

Medications:

Are you receiving allergy medication YES NO

If yes, please specify:

Do you take any of the following:

Aspirin YES / NO

Sulfa Drugs YES / NO

Penicillin YES / NO

Other YES / NO

Please List Below:

Do you have any of the following conditions:

Back Problems YES / NO

Blood Clot/Phlebitis YES / NO

Ear, Nose and Throat Trouble YES / NO

Eye Trouble YES / NO

Head Injury with Unconsciousness YES / NO

Hospitalizations/Surgery YES / NO

If yes, specify:

Hypoglycemia YES / NO

Malaria YES / NO

Mononucleosis YES / NO

Pregnancy YES / NO

Recurrent Bladder Infections YES / NO

Recurrent Diarrhea YES / NO

Rheumatic Fever YES / NO

Sexually Transmitted Diseases (STDs) YES / NO

Skin Diseases (acne, eczema, psoriasis) YES / NO

Strep Throat YES / NO

TMJ (jaw problems) YES / NO

Transfusions YES / NO

If yes, date:

Varicose Veins YES / NO

Alcohol/Drug Dependency YES / NO

Anemia/Blood Disease YES / NO

Anxiety YES / NO

Arthritis YES / NO

Asthma YES / NO

Bulimia YES / NO

Cancer, Cyst, Tumor YES / NO

Diabetes YES / NO

Depression YES / NO

Epilepsy, Seizures YES / NO

Gallbladder Trouble YES / NO

Heart Murmur/Disease YES / NO

High Blood Pressure YES / NO

Kidney Disease/Infections YES / NO

Liver Disease, Jaundice YES / NO

Migraines YES / NO

Obesity YES / NO

Peptic Ulcer Disease YES / NO

Psychological Problems YES / NO

Thyroid Disease YES / NO

Tuberculosis YES / NO

Other Chronic Conditions YES / NO

Please List Below:

I understand that it is my continuing responsibility to inform of any previous medical conditions, injuries or surgeries prior to my first class and at such other times as I acquire information as to same.

Have you practiced yoga or cardio kickboxing before this class? YES NO

If so, what style do you mostly practice?

For and in consideration of being allowed to receive Yoga and/or Cardio Kickboxing Training from , and the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned agrees to the following:

1. I, , do fully comprehend and assume all risks involved in participating in Yoga and/or Cardio Kickboxing Training. I have been advised by , to consult my physician prior to my participation in Yoga and/or Cardio Kickboxing Training to insure that I am physically able to engage in strenuous physical activity.

2. Being fully cognizant, and assuming all risks involved in the Yoga and/or Cardio Kickboxing Training from , I do hereby remise, release, quitclaim, and forever discharge , her employees or agents, administrators, successors and assigns, of and from any and all manner of actions, suits, damages, judgments, executions, claims, or demands whatsoever in law or equity, or otherwise, against , her employees or agents, administrators, successors and assigns, which I, my heirs, executors, or administrators hereafter can, shall or may have, for, upon or by reason of any injury that I may sustain or incur while participating in the Yoga and/or Cardio Kickboxing Training of , or while engaging in physical conditioning exercises.

3. In consideration of being allowed to participate in said Yoga and/or Cardio Kickboxing Training of , I do hereby assume all risks of my involvement and do covenant and agree not to bring legal action for damages should I sustain any injury, and do further release , her employees or agents, administrators, successors and assigns from all acts of active or passive negligence on the part of , her employees or agents, administrators, successors and assigns.

4. I also agree to INDEMNIFY AND HOLD , her employees or agents, administrators, successors and assigns harmless from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including attorney’s fess brought as a result of my involvement in said Yoga and/or Cardio Kickboxing Training and to reimburse them for any such expenses incurred.

5. I understand and agree that teaches Yoga and/or Cardio Kickboxing from various locations and I do covenant and agree not to bring legal action for damages should I sustain any injury at any such location, and do further release the owner or lessee of such location, its employees or agents, administrators, successors and assigns from all acts of active or passive negligence on the part of said owner or lessee, its employees or agents, administrators, successors and assigns.

6. In this Agreement, any reference to a party includes that party's heirs, executors, administrators, successors and assigns, singular includes plural and masculine includes feminine.

Witness my signature this (date).

If Client is under the age of eighteen (18), Parents or Guardians must also sign the following Agreement.

The undersigned , declare that we are the Parents or Legal Guardians of the above named Client. In such capacity as Parents or Legal Guardians, we acknowledge that we have carefully read this Agreement and we do hereby assume all responsibilities and obligations of Client as set for therein and do specifically agree to indemnify and hold and the Owner or Lessee of the location from which teaches, their employees or agents, administrators, successors and assigns, assigns harmless as set forth in said Agreement and join in all waivers and releases of said Agreement.

CONSENT AS TO MEDICAL CARE

In addition, in the event of an emergency or non-emergency situation requiring medical treatment, the undersigned Parents or Legal Guardians hereby grant permission for any and all medical and/or dental attention to be administered to Client, in the event of an accidental injury or illness. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. The undersigned request that we be contacted as soon as possible in the case such medical care is necessary or appears to be necessary.

WITNESS our signatures as of the day of , 20.