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Medical Release Form
Name:_____________________________________________Date:_____________________
Address:____________________________________________________________________
Home Phone: ________________________ Cell Phone: ______________________________
Work Phone: _________________________
Emergency Contact & Phone number: _____________________________________________
Relationship to you: _______________________________________________
Doctor’s Name _________________________________
Doctor's Office Number:__________________________
Doctor’s Address: ______________________________________________________________
Release
I understand that my participation in any exercise program while I am pregnant, or immediately following a pregnancy, may increase the risk of injury to myself and possibly my unborn child. I have consulted with my physician regarding my participation in FitMommi classes. My physician has given me permission to participate in this exercise program.
I understand that I will not participate in a FitMommi program for at least six weeks after giving birth. I have consulted my physician prior to attending any FitMommi class to obtain his or her professional approval.
I understand that I will not be accepted into a FitMommi program without this release.
I agree to assume all risk related to my participation in FitMommi classes or associated events. I hereby release and hold harmless FitMommi, its owners, instructors and the partners of the FitMommi program. I further agree, on behalf of myself and my estate, to reimburse and make good to FitMommi any loss or cost FitMommi may have to pay as a result of any such action, claim or demand.
I understand that the level of my participation in any FitMommi curriculum must be determined by me, in consultation with my physician.
I understand my FitMommi class instructor is not a doctor, nurse or emergency medical technician, and that the instructor and FitMommi by making the corresponding fitness classes available, are not undertaking any responsibility regarding my medical condition.
I have read and understand this release and agree to its terms and conditions.
In witness thereof, I have signed this release.
____________________________________________________________________
Participant Signature Date
____________________________________________________________________
Witness Signature Date
This form must be given the Yoga instructor at or before
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