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Fall In Balance



Name________________________________  D.O.B_________________  Date______________


Home Phone____________________ Cell____________________ E-mail_________________________


Address __________________________ City_______________ State_______ Zip___________




Emergency Contact______________________ Relationship____________ Phone____________



   Physical activity should not be hazardous for most people. 




            I understand the risks associated with exercise and recognize that I hereby knowingly and voluntarily waive my right of action of any kind arising from which any liability which may or could occur, to Irene Speirs and/ or PAMA and/or agents that may occur in my participation in any activity on the premises owned or leased by any of the above.  I also understand that there are no refunds under any circumstance. I give my permission to be added to the e-mailing list.



        Signature _________________________________ Date_______________

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