Polynesian Dance & Fitness

 

 

Liability Waiver / Informed Consent Form

 

 

 

 

“I, _______________________________, have enrolled in Barbara Dempsey’s “Aloha Allure Dance and Fitness” program. I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. I acknowledge that my enrollment and subsequent participation in purely voluntary and in no way mandated by Aloha Allure.

 

(_______) “In consideration of my participation in this program, I hereby release Barbara Dempsey “Aloha Allure Dance & Fitness” and its agents from any claims, demands, and causes of action as a result of my voluntary participation and enrollment."

 

(________) “ I fully understand that I may injure myself as a result of my enrollment and subsequent participation in this program and I, hereby release Barbara Dempsey “Aloha Allure Dance & Fitness” and its agents from any liability now or in the future for conditions that I may obtain.

These conditions may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, injuries to back, injuries to foot, or any other illness or soreness that I may incur, including death.”

 

I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS.

 

 

 

 

Participant Signature: ___________________________

 

 

Date: ___________________________