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Date ____/_____/________ Name_________________________________________________________ Address__________________________________________________________________________________ City____________________________ Zip Code________________ Home Phone (_____)______-________ Cell Phone (____)-______-________ E-mail____________________________________Date of Birth___/____/____ Emergency Contact Name___________________________________________ Address__________________________________________________________________________________ City____________________________ Zip Code________________ Home Phone (_____)______-________ NOTICE: It is highly recommended that you seek your physician’s advice before beginning any new health/fitness program. WAIVER AND RELEASE This release is entered into between the undersigned and BreckFit, LLC, its officers, members, affiliates, employees and executors. The purpose of BreckFit, LLC is to provide general fitness instruction and coaching for various levels of individuals. The undersigned hereby acknowledge that the following was explained to me and/or agree to the following: 1. Acknowledges that Ariel Cabana, sole member of BreckFit, LLC, is not a physician or dietician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice. 2. Acknowledges that the undersigned has been told if they feel tired, feel pain, feel dizzy, or feel out of the ordinary in any way either related to exercise, or otherwise, that the undersigned should contact a physician at once. 3. Acknowledges that fitness boot camps, weight training, obstacle courses, running, and other related fitness activities can be a test of one’s mental and physical limits and carry with it potential for damage or loss of property, serious injury and death. That the undersigned assumes the risks of participating in these types of events/activities including the elements of a natural environment, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind BreckFit, LLC for the undersigned participating in said fitness activities. The Undersigned agrees that this is the full agreement between the parties, that BreckFit, LLC, including its sole member Ariel Cabana, has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion. Customer client agrees to confidentiality with respect to BreckFit, LLC and all services provided by same. The undersigned agrees to refrain from disclosing, copying, or distributing, directly or indirectly, any specific workout of BreckFit, LLC, including any written document distributed as part of the fitness program, to any third parties. ____________________________________________ Your signature (Parent or Guardian if under the age of 18) By signing this waiver, I agree to the above terms and conditions. Name First Name____________Last Name____________