PILATES BARRE

Waiver

Client Intake, Photography Release & Release of Liability

Name *

Date of Birth * (MM/DD/YYYY)

Email *

Phone Number *

Address *

Are you pregnant? *

Do you have any injuries, health issues or special needs we should know about?*

If you answered YES to the above question, please describe:

By checking this box, I agree and acknowledge I should consult my medical practitioner prior to participating in any activities with Pilates Barre, LLC or using its facilities, especially if I had, have, or develop a serious health condition, including but not limited to stroke, lupus, hernia, numbness in the extremities, orthopedic condition, heart condition, asthma, breathing problems, faintness, dizziness, loss of balance, injury/surgery/concussion, or current pregnancy.*

Emergency Contact First and Last Name:*

Emergency Contact Phone number:*

By checking this box, I agree Pilates Barre, LLC enforces a 12-hour cancellation policy. Due to the nature of scheduled workouts, it is important to your instructor and fellow exercising partners that you attend every session you schedule. For this reason, if you do not contact the studio (email/online) within 12 hours to cancel your appointment, you will be charged the full amount fo that session. In addition, if you arrive late to your session or must leave early, the full charge or the 45 minute class applies. Exceptions to the late charge policy are up to the discretion of Pilates Barre LLC only and are non-negotiable.*

Photography/Media Consent and Release:

I hereby consent and authorize Pilates Barre, LLC (the “Company”) to take photographs or motion pictures of me; or to produce videotapes, audiotapes, closed circuit television programs, web casts, or other types of media productions that capture my name, voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form).

I authorize the Company to copyright the Materials, and I authorize the Company to use, reuse, copy, publish, display, exhibit, reproduce, license to the third party, and distribute the Materials in any educational or promotional materials or other forms of media, which may include, but are not limited to marketing publications, catalogs, articles, magazines, recruiting brochures, billboards, websites or publications, electronic or otherwise, without notifying me. I waive any right of privacy associated with the Materials as well as the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. I also agree that the Company may identify me by name and other identifying information.

I agree that I am participating on a voluntary basis and I will not receive any payment from the Company for signing this release or as a result of any publication of the Materials.

I hereby hold harmless and release and forever discharge the Company from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I am 18 years of age and am competent to contract in my own name, or if not, that I have secured the signature of my parent or legal guardian. I have read this release before signing below and I fully understand that contents, meaning, and impact of this release.

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Please Enter Date*(MM/DD/YYYY)

Release and Indemnity Agreement

THIS RELEASE AND INDEMNITY AGREEMENT (“Release”) is made by the undersigned adult (the “Participant”), to release and indemnify Pilates Barre, LLC, a California limited liability company, its parents, subsidiaries, and affiliates, and all of their respective members, employees, heirs, successors, agents, contracts, and assigns (collectively the “Released Parties”) Participant, or the parent or legal guardian of the Participant if under that age of eighteen (18) years old, on Participant’s own behalf and on behalf of the other members of the Participant’s family, including Participant’s spouse, parents, children, heirs, and assigns, (singularly and collectively referred to as “Releasing Parties”) hereby grants to Pilates Barre, LLC this full release and indemnification as consideration in exchange for permitting Participant to participate in this exercise program.

Participant is voluntarily participating in the activity with full knowledge, understanding, and appreciation of the risks inherent in any physical exercise and expressly assumes all risks of injury and even death which could occur by reason of participant’s participation.

Participant, including the Releasing Parties, hereby releases the Released Parties from any liability and agrees not to sue the Released Parties with respect to any cause of action for bodily injury, property damage, or death arising out of any of the activities or programs herein or in the use of any equipment at this or any other premises of the Released Parties.

Participant hereby assumes full responsibility for risks of bodily injury, property damage, or death to Participant due to the ordinary negligence or gross negligence of the Released Parties and the ordinary negligence, gross negligence, or willful misconduct of any third party including others participating in the exercise program.

All personal property brought to the studio is brought at the sole risk of the Participant as to its theft, damage, or loss. The Released Parties are not responsible for any personal items left by Participant in this facility.

Participant hereby agrees to permit Pilates Barre, LLC to use without compensation images of Participant as a program participant in internal and external promotional material. This includes any printed material, broadcast and print advertising, promotional videos, and websites which are produced or published by Pilates Barre, LLC. All such materials are the property of Pilates Barre, LLC.

Participant expressly agrees that the terms of the release and indemnity contained herein are intended to be as broad and inclusive as is permitted by the laws of California. Any provision of this Release found to be invalid by the courts having jurisdiction shall be invalid only with respect to such provision or portion and the remainder shall be enforced to the greatest extent possible.

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Please Enter Date*(MM/DD/YYYY)

PILATES BARRE

Waiver

Photography/Media Consent and Release:

Release and Indemnity Agreement

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