WAIVERS | Human Movement Lab

Liability Waiver & Media Release

First name

Last name

Date of Birth

Phone

Address

Do you have a doctor’s permit to participate in intense physical activities?

Yes

Please specify anything we should know about in regards to your physical health/past injuries.

Initials

Emergency Contact Name

Emergency Contact Relationship to You

Emergency Contact Phone

Emergency Contact Email Address

Media Release. I understand that photo and video might be taken during Human Movement Lab Programming, as a way to advertise the business. I understand that if I do NOT want my likeness on any public images, I should request that via email.

I declare that the info I’ve provided is accurate & complete

I hereby release Human Movement Lab/Kim Holman from any liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I have read the HML Policies on the website:read here

Your Signature

If signing for a minor, minor's name

Thanks for submitting!