EmailMeForm
Build Your Own Smoothie Cleanse
Select 8 smoothies below!
Name
First
Last
Email
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Phone
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Please list any food allergies:
Submit a custom order by listing your choices below
(include smoothie name and quantity):
Example: Jumpy Monkey with protein & spinach – Qty: 2
*Must select 8 smoothie options
Smoothie Options
Clean Green with protein
Berrylicious with peanut butter
Wedding Cake with spinach
Strawberries N Cream with collagen
Jumpy Monkey with protein and spinach
Up Beet with protein
Refresh with flax
Reverse (includes protein and spinach)
Power Smoothie with protein
Vanilla Fuel Up with spinach
Milky Whey with flax
Beach Breeze with protein
Super C with collagen
Mango Medley with protein
Funky Monkey with protein and spinach
Select Cleanse Week:
*
June 3-6
June 10-13
June 17-20
June 24-27
Pickup on Tuesday
Credit Card
Smoothie Cleanse: $89
Card Number
Expiration
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3 or 4 digit number printed on the back/front of your credit card
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Liability Waiver:
I understand that I (Including me and/or my children) risk injury and even death if I participate in aerobic and other exercise programs which involve using any and/or all of the services, equipment, machinery and facilities at Spoga Inc. if :
1. A medical doctor has not first determined that I am physically fit to participate: and
2. I participate in exercise/fitness activities or use equipment and /or facilities without first being
instructed by Spoga staff in the correct way to participate in the activities or use of the equipment.
I realize that I, not Spoga Inc., am responsible for having my own health evaluated before I participate in any exercise program, and for receiving instruction from Spoga’s staff before using any of the services, equipment or facilities. Unless, I notify Spoga in writing to the contrary, I understand and agree that Spoga is entitled to assume my physician has approved for my own participation in the exercise/fitness activities I participate in, and that I have received instruction form Spoga staff on the correct way to use any service, equipment and/or facility at Spoga Inc.
With the full knowledge of the risks involved in participating in aerobic and/or exercise programs and using Spoga’s services, equipment and/or facilities, and in consideration of my membership at Spoga, I release Spoga Inc., its members, employees and agents, from any responsibility for damages losses or injuries I suffer while participating in any aerobic and/or exercise program, or using any equipment and/or facility at Spoga Inc. I also agree to defend any claim or lawsuit, pay all attorney’s fees and costs, indemnify and hold harmless Spoga Inc. , its members, employees, and agents from any and all liability, claims and/or demand for damages, injuries, death, losses, costs, or expenses of any kind resulting from or which are claimed to have resulted from anyone admitted to Spoga as my guest or my own participation in any aerobic and/or exercise program or use of any equipment and/or facility of Spoga Inc.
I understand that all spa services vary in result based on the individual. I acknowledge that there are potentially dangerous conditions that are present when receiving spa treatments. I also understand that Spoga, Inc. is not responsible for any allergic reaction you may encounter from stylists and/or The Power Bar products.
I acknowledge receiving, and reading, and do understand the agreements contained herein, including the release of liability and hold harmless obligations.
I authorize Spoga Inc. to verify the information contained in this membership application and agreement.
Please sign below:
Signature
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**Smoothie Cleanse - Build Your Own
PROMO CODE
Total
$89.00