Name *
Phone *
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
If you are under 18, you will need to complete your waiver on the first day of class.
PLEASE READ THIS FORM CAREFULLY AND BE AWARE THAT WHEN REGISTERING FOR ZUMBA® YOU WILL BE WAIVING AND RELEASING ALL CLAIMS FOR INJURIES OR CONDITIONS YOU MAY SUSTAIN OR ACQUIRE FROM PARTICIPATING IN ZUMBA® CLASS INSTRUCTED BY AMY WHITSEL, PATTERSON PARK CHURCH, OR GUEST INSTRUCTORS. Agreement of Release and Waiver of Liability: The undersigned, in consideration for participation in Zumba® hereby agrees to the following: 1. The undersigned recognizes that Zumba® requires physical exertion, which may be strenuous and may cause physical injury and the undersigned is fully aware of the risks and hazards involved. 2. The undersigned understands that it is the their responsibility to consult with a physician prior to and regarding participation in Zumba® class. The undersigned represents and warrants that the undersigned is physically fit and has no medical condition that would prevent the undersigned’s full participation in the Zumba® class. 3. In consideration of being permitted to participate in Zumba® class, the undersigned agrees to assume full responsibility for any risks, injuries or damages, known or unknown, which the undersigned might incur as a result of participation. 4. In further consideration of being permitted to participate in the Zumba® classes, the undersigned knowingly, voluntarily and expressly waives any claim the undersigned may have against Patterson Park Church, Amy Whitsel, or her assistants, for injuries or damages that the undersigned may sustain as a result of participating in classes held by Patterson Park Church, or Amy Whitsel, jointly or severally. The undersigned acknowledges that the undersigned has provided accurate and true information with regard to the Zumba® class registration information and acknowledges that the undersigned has read and agrees to the above release and waiver of liability, fully understands its contents, and agrees to the terms and conditions stated therein. In the event of any emergency, the undersigned authorizes medical attention from any licensed hospital, physician and/or medical personnel, any treatment deemed necessary for immediate care and agree that the undersigned will be responsible for payment of any and all medical, hospital or emergency services rendered. It is recommended that the undersigned should review their health insurance coverage for applicability to Zumba® classes, as the absence of health insurance coverage does not render Patterson Park Church and Amy Whitsel responsible for payment of medical, hospital, emergency, expenses or lost wages as a result of participation in Zumba®. The undersigned acknowledges that he/she has read this Waiver and Release of All Claims and Authorization and hereby agrees to be bound by the terms thereof.