Let’s work together Interested in starting with Independence Movement? Fill out your info and we’re all set to go! Name * First Name Last Name Email * Phone (###) ### #### Date of Birth * MM DD YYYY Emergency contact person and phone number * Do you have any health or injury history that impacts your ability to exercise? If yes, please provide details * By ticking these boxes I agree to participate in personal fitness training and / or group exercise classes of my own free will and that: Participation in personal fitness training and group exercise shall be entirely at my own risk Independence Movement shall not be held liable for any loss or damage however caused arising out of my participation I will abide by all instructions delivered by Independence Movement during the course of my personal fitness training and / or on display in the training environment It is my obligation to disclose any injury, illness or condition that may impact on my ability to participate Thank you!