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Name *

First Name

Last Name

Phone *

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Preferred Date of Service *

MM

DD

YYYY

Preferred Time of Service *

Hour

Minute

Second

AM PM

INFORMED CONSENT & WAIVER & RELEASE OF LIABILITY: *

I have volunteered to participate in a program of progressive exercise and to retain the services of SYMMETRY STUDIO to receive physical training. I intend to assume all risks of injury from my participation. To that end I acknowledge & agree to all of the following:

Risk of Injury *

The muscular conditioning program utilizes the Pilates method and Gyrotonic®. During the exercise there exists a potential for muscular soreness or stiffness, abnormal blood pressure, fainting and disorders of heartbeat. I assume all of the foregoing risks and accept personal responsibility for any other injuries I may suffer.

Right to Choose *

I know I have the right to choose what exercises I do or do not perform in addition to withdrawing from any exercise at any time.

Liability *

I hereby fully & forever release, discharge and hold harmless Jeanette Davis-Esposito, her agents and officers from and against any and all liability to me, my heirs and next of kin, for any and all claims, demands, rights of action, causes of action, losses or damages, on account of injury including death or damage to property right to sue any of the foregoing for any injuries I may sustain or losses I may incur, whether known or unknown resulting from the activity described above.

Equipment *

SYMMETRY STUDIO has not made any representations to the nature and quality of the facilities or equipment to be used as to any other matter related in my participation in the foregoing activity. I understand that the “RELEASEES” enumerated above or otherwise owe no duty or obligation to me.

Concent & Waiver Agreement *

I have read and understand this INFORMED CONSENT & WAIVER & RELEASE OF LIABILITY & it accurately sets forth my intentions & I agree to be bound by its provisions.

24 HOUR CANCELLATION POLICY: *

All sessions require a 24 hour cancellation notice. You will be charged the full price of your session if you cancel less than 24 hours in advance. This policy is in place to ensure the livelihood and time of the trainer is respected. Thank you for your cooperation in this matter.