LIVE STREAM Health Waiver

To register to our virtual gym please fill out the following medical form

First Name

Email Address

Last Name

Date of Birth

1. Has your doctor ever declared, or prescribed pills for, having a heart condition and/ or that you should only do physical activity recommended by a doctor?

Yes

2. Do you feel pain in your chest, have lost balance or consciousness, or have had bone or joint pain when you do physical activity?

Yes

(SYNERGY FITNESS & MASSAGE, LLC) 29 S. NORWICH ROAD TROY, OH 45373 Agreement and Release of Liability - *Please note that this Release Waiver covers liability at any and all locations where Salsa City Studio (Synergy Fitness & Massage, LLC) Fitness classes are held. I the undersigned, hereby expressly and affimatively state that I wish to participate in the exercise class.

"I, the undersigned via Initials below, hereby expressly and affirmatively state that I wish to participate in the Salsa City Fitness exercise class via synergy fitness LLC. I realize that my participation in this activity involves risks of injury, including but not limited to muscle strain, joint sprains ‘s, broken bones, slips, trips, falls, heart attack, stroke, and even the possibility of death. I also recognize that there are many other risks of injury including serious disabling injuries, which may arise due to my participation in the activity, and that it is not possible to specifically list each and every possible injury risk. However, knowing the material risks and appreciating, knowing risks of injury, all other possible risks of injury, and even the risk of death, which could occur by reason of my participation. I subjectively understand the risk of my participation in this activity, and knowing and appreciating these risks voluntarily choose to participate, assuming all risks of injury or even death due to my participation. I do here by wave, release, and forever discharge all employees, representatives, and all others from any and all responsibilities or liability or damages resulting from my participation in this activity.”

Initials

Today's Date

Thanks for submitting- you are now cleared to participate in our live-streaming classes!