EmailMe Form - Fall Wellness Workshop!

Name *
First Last
Home Phone
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Email *
Mobile Phone
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Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
How Did You First Hear About This Class? *
Flier
MNA Gazette
Friend
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Mailing
Other (Please Describe Below)
Other:
Informed Consent and Hold Harmless/Release Agreement:
I understand that participation in exercise activities involves a certain degree of risk. I have carefully considered the risk involved and I understand that participation in these activities is entirely voluntary. I understand that class participants will be shown multiple modifications for each exercise and that only I know best which modifications will be the safest for me. I understand this class is not about competition and that all participants should strive to comfortably self-challenge while exercising at the level appropriate to each individual's skill set and health. By printing my name below, I release the Wil-‐Mar Neighborhood Center and the instructor from any and all claims of liability arising out of my participation in this class. Photos may be taken during a session and I allow these to be used for educational and marketing purposes. *
I have read and agree to the above statement.
Any comments or questions?