Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

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