Include Name, Relationship & Contact Info

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you perform physical activity?

Have you had chest pain when you were not doing physical activity?

Do you lose your balance due to dizziness or do you ever lose consciousness?

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, rnanorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?

Are you pregnant now or have given birth within the last 6 months?

Have you had a recent surgery?

I wish to participate in the exercise and training program offered by CareerFit Mom (CFM). I understand there are inherent risks in participating in a program of strenuous exercise and I do so strictly at my own risk. I further agree that CFM, Beth Yarzab and/or any fitness professional working with CFM shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program. I expressly release and discharge CFM, its owners, employees, agents and/or assigns from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by an intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.

I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during the workshop. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform CFM or alternate staff.

I understand that CFM may photograph and/or video tape workshop events/sessions and I provide CFM the absolute right and permission to use these pictures/images for any lawful promotional, advertising or marketing purpose.

I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.