Liability Form | Fitness

To register for classes, please fill out the following medical form.

First Name

Last Name

Email Address

Phone Number

Legal Guardian Name & Relationship (if different from client, i.e. client is a minor)

Emergency Contact Information

Name

Relationship

Phone number

Please note: Personal information is only used for contact or emergency purposes. Your information will not be sold to or given to anyone other than Kaethe Birkner or a representative of Kaethe, including a substitute instructor, which would only happen in event of an situation or emergency which prevents her from contacting you herself.

By applying my digital signature below, I, or my legal guardian, hereby declare the information above to be accurate and complete. Sign and submit to continue to the next form.

Initials

Today's Date

Emergency Contact Information

Personal Information and

Release Form