Waiver and Policies

NAME:______________________________________________________________

DOB:_____________________

ADDRESS:______________________ ___________

CITY & ZIP: _______________________________________

PHONE:______________________________________

EMAIL:___________________________________________

EMERGENCY CONTACT:_________________________

PHONE NUMBER:___________________________________

Do you have any physical disabilities or injuries? If yes, please explain:____________________________________

Waiver of Liability/Indemnification and Policies

It is important to consult your physician prior to beginning and exercise program. Fitness programs involve physical

contact and there is a risk that injury may result. While understanding the risk, the undersigned member assumes the

risk of injury and assumes responsibility for his or her own safety.

In consideration of receiving fitness instruction, the undersigned member does for themselves, their heirs, their

executors, and administrators indemnify’s waive, release, discharge, and hold harmless Tina Gamache, Fortify Training

LLC, it’s owners, officers, employees, agents, coaches, personal trainers, representatives, successors, and/or assigns,

Spicket River Brewery, and any other person or entity associated with instruction from and against any and all damages,

injuries, losses, or expenses, arising from, but not limited to the participation in the fitness program, the action or

omission of any of the above representatives, or publication of any pictures, photos, website publication and video

reproduction, and the transportation of members to and from said academy.

MEMBER SIGNATURE:__________________________________________________DATE:____________________

WITNESS:____________________________________________________________DATE:____________________