I am 18 or older, or the legal guardian for the minor listed below *

Name *

First Name

Last Name

Phone

(###)

###

####

Marketing Release *

I understand that if any photographs and/or video of me are taken, they may be used for promotional/marketing purposes, and I hereby authorize Radius Physical + Sports Rehab to publish images taken of me for the use in print, online, and video-based marketing materials and other publications.

Waiver *

I am consenting to participate in exercises, stretches and rehabilitation type activities. As with all athletic activities there is a risk of injury. I do hereby fully release, discharge and indemnify Radius Physical + Sports Rehab and Fit4Mom and its officers, agents, servants, and employees from any and all claims resulting from injuries, including death damages and losses I sustain or arising out of, connected with, or in any way associated with activities or participation in the workshop.