Name *

First Name

Last Name

Risk *

I will receive information and instruction while participating in the class at Bett Pilates. I recognize that this class will require physical exertion, which may be strenuous and may cause physical injury and I am fully aware of the risks and hazards involved.

Yes

Responsibility *

I understand that it is my responsibility to consult with a physician prior to and regarding my participation in this class or any other activity associated with Hilary Opheim Pilates. I represent and warrant that I am physically fit and I have no medical conditions, which would prevent my full participation in the Pilates workout. If I have any medical conditions they are listed clearly and accurately on the Client Information form

Yes

Injury/Damage *

I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participating in the program.

Yes

Waiver *

I knowingly, voluntarily and expressly waive any claim that I may have against Bett Pilates for injury or damages that I may sustain as a result of my participation.

Yes

Representations *

Heirs, my legal representatives or I, forever release and waive any liabilities against Bett Pilates for any injury or death incurred by my voluntary participation in this class.

Yes

Photo *

I agree to allow Bett Pilates to use my likeness in publicity, websites and social media. I may revoke this privilege at any time in writing.

Yes

No

Read & Understand *

I HAVE READ THE ABOVE RELEASE & WAIVER OF LIABILITY AND FULLY UNDERSTAND ITS CONTENTS. I VOLUNTARILY AGREE TO THE TERMS AND CONDITIONS STATED ABOVE

Yes

Date *

MM

DD

YYYY