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_______________