Health and Liability Waiver
Please take a minute to fill in the following info. This form must be filled out to participate in a private session. class, activity or event at Lighthouse Studio OBX.
First Name
Last Name
Phone Number
Email
Address
Emergency contact and phone number
Do you understand it is your responsibility to consult with a physician prior to and regarding your participation in a fitness program?
Yes
No
Do you acknowledge you are aware of your own health and physical condition and that any exercise program may be injurious to your health?
Yes
No
Do you release representatives of Lighthouse Studio OBX and Lighthouse Studio OBX from liability for accidental injury or illness which may incur as a result of participating in the activity you have signed up for?
Yes
No
Do you hereby assume all risks connected to the participation in the activity you have signed up for?
Yes
No
Do you agree to disclose any limitations that would affect your ability to participate in the activity you have signed up for?
Yes
No
Please specify anything we should know about:
Do you give Lighthouse Studio OBX permission to use your name and/or your image and/or a video of you for advertising purposes, including but not limited to social media, online advertising and print ads.
Yes
No
I agree to the terms & conditions
Your Signature
*
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