QPT PERSONAL INFORMATION & RELEASE

PERSONAL INFORMATION
Name:
Date of Birth:
Date Format: DD slash MM slash YYYY
Age:
Address:
City:
State:
Zip:
Phone
Email
Emergency Contact:
Phone
Relationship:
ACCIDENT & LIABILITY WAIVER & RELEASE
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH PERSONAL TRAINING, including by way of example and not limitation, any risk that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault. I certify that I am physically fit, have sufficiently prepared or trained for participation in the activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity. I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from the activity.
I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND I SIGN IT OF MY OWN FREE WILL.
PRINT NAME:
Signature
DATE:
Date Format: MM slash DD slash YYYY
PARENT/GUARDIAN NAME:
Signature
DATE:
Date Format: MM slash DD slash YYYY
If under 18 years old, Parent or Guardian must also sign
PHOTO & VIDEO WAIVER & RELEASE
I hereby give Quantum Performance Training the right to use video footage and or photographs of myself. I agree that the video footage and or photographs will be property of Quantum Performance Training and I waive all rights including the right to inspect and or approve copy of voice commentary. The pictures and or video footage may be used as Quantum Performance Training sees fit in the publication of educational or promotional materials and for any other lawful purpose.
I give permission to be videotaped and or photographed:
PRINT NAME:
Signature
DATE:
Date Format: MM slash DD slash YYYY
I do not give permission to be videotaped and or photographed:
PRINT NAME:
Signature
DATE:
Date Format: MM slash DD slash YYYY