|Instruction in Chen Style Tai Chi
Name of Participant (First and Last): ______________________________________________________
City: ______________________________ State: _______ Zip: ______________________
Home Phone: ____________________________ Cell Phone: ____________________________
Emergency Contact Name: _____________________________ Phone: _________________________
INFORMED CONSENT FOR EXERCISE PARTICIPATION
I desire to engage voluntarily in an exercise program given by Ann Arbor Tai Chi. I understand that the activities may be strenuous, and may require me to do body movement that I am not familiar with in order to improve overall fitness. I understand that I am responsible for monitoring my own condition throughout my workouts. Should any unusual symptoms occur, I will cease my participation.
In signing this consent form, I affirm that I have read, accept and understand this form in its entirety and that I understand the nature of exercise. I know that there may be risks associated with fitness classes and willingly accept those possibilities. I know that it is my responsibility to ensure my own safety. I take full responsibility for my own health and safety in participating in the fitness class and to the extent I deem advisable, will consult a physician before participating in any of the activities.
AGREEMENT AND WAIVER / RELEASE OF LIABILITY
In consideration for being allowed to participate in this activity, which I do freely and voluntarily for my own personal benefit, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns to:
Therefore, intending to be bound and as a condition of being allowed to participate in the fitness class, have freely signed this waiver on the date indicated.
Participant Signature: _____________________________ Date: __________
Parent/Guardian Signature (Required if under 18 years old): ____________________________
Print Parent/Guardian Name: ________________________________________