Informed Consent Form for Zumba Fitness

INFORMED CONSENT FORM

For: Zumba Fitness With Xanthi Pinkerton, Licensed Zumba Fitness Instructor

Participant Contact Information:

General Statement of Program Objectives and Procedures:

I understand that this physical fitness program includes exercises to build the cardiorespiratory system (heart and lungs), the musculoskeletal system (muscle endurance and strength, and flexibility), and to improve body composition (decrease of body fat in individuals needing to lose fat, with an increase in weight of muscle and bone).

Description of Potential Risks:

I understand that the reaction of the heart, lung, and blood vessel system to exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart attacks. If adequate warm-up, cool-down, and safety procedures are not followed, I understand this may lead to musculoskeletal strains, pain and injury. I understand that Xanthi Pinkerton, and/or Zumba Fitness, LLC shall not be liable for any damages arising from personal injuries sustained by participant during the Zumba Fitness program. Participant engaging in the Zumba Fitness program does so at his/her own risk. Participant assumes full responsibility for any injuries or damages which may occur during the program.

I hereby fully and forever release and discharge Xanthi Pinkerton, and/or Zumba Fitness, LLC, and Common Ground, A Covenant Church its assigns and agents from all claims, demands, damages, rights of action, present and future therein. I understand and warrant, release and agree that I am in good physical condition and that I have no disability, impairment or ailment preventing me from engaging in active or passive exercise that will be detrimental to heart, safety, or comfort, or physical condition if I engage or participate. I state that I have had a recent physical checkup and have my personal physician's permission to engage in aerobic and/or anaerobic conditioning.

Description of Potential Benefits:

I understand that a program of regular exercise for the heart, lungs, muscles and joints, has many benefits associated with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function, and decrease in heart disease.

I have read the foregoing information and understand it. Any questions which may have occurred to me have been answered to my satisfaction.

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

For Zumba Fitness With Xanthi Pinkerton, Licensed Zumba Fitness Instructor

In consideration for receiving permission to participate in ZUMBA FITNESS group exercise classes (1) I (we) hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Xanthi Pinkerton and/or Zumba Fitness LLC, Common Ground, A Covenant Church, their officers, agents, servants or employees (herein referred to as RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such activity, or while in, or upon the premise where activity is being conducted. (2) I am fully aware of the risk involved and hazards connected with any exercise program, including but not limited to the risks as noted herein. I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage of property owned by me, as a result of being engaged in such activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise. (3) I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damages or cost, including court costs and attorney fees, that they may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise. (4) I have been advised to consult a physician before attending this or any Zumba Fitness classes. I understand that Xanthi Pinkerton and/or Zumba Fitness LLC, Common Ground, A Covenant Church will not be responsible for any Medical Costs associated with an injury that I may sustain. I have disclosed all physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in Zumba Fitness. (5) It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of California.

In SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act or deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.