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Registration/Release of Liability Participants Name:_____________________________________________(Age):_____________ Parent Contact Information and Primary Emergency Contact Full Name:______________________________________________________________________ Relation to the child:______________________________________________________________ Phone number/Cell phone:__________________________________________________________ Address: _______________________________________________________________________ e-mail: _________________________________________________________________________ Student Information Please list anything that could negatively affect your child’s class experience (a disability, injury, allergies, asthma, recent illness, etc.__________________________________________________ Any additional information:_________________________________________________________ Parent Consent and Liability Waiver As parent/guardian, I give my consent for my child to participate in physical activity at The Groove Fitness Studio,LLC. I recognize the risks of injury common to any fitness program. I hereby waive and release The Groove Fitness Studio,LLC, the Instructor (Jen Burgmeier), volunteers and employees from any and against all claims of liability for any accidental injury or illness which may incur as a result of participating in the said fitness program including accidents or injury while on or about their premises, or while on off-site performances or activities. I hereby assume all risks connected therewith and consent my child to participate in said program. In the event of any emergency, I authorize medical attention from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my child’s immediate care and agree that I will be responsible for payment of any and all medical services rendered. Therefore, each person registering their family member should review their own health insurance policy for coverage. It must be noted that the absence of health insurance coverage does not make the employees of The Groove Fitness Studio,LLC, or the Instructor, Jen Burgmeier, to be automatically responsible for payment of medical expenses. This acknowledgement of Risk and Waiver of Liability has been read, understood completely and signed voluntarily by the parent/legal guardian of named student.

_____________________________________ Parent/guardian signature

________________________ Date

I give my permission for Jen Burgmeier to use photos of my child (no names will be used) on her website: or on printed materials. Said photos will be used appropriately and solely for the marketing of The Groove Fitness Studio LLC, online or in printed materials. I reserve the right as a parent to withdraw my permission at any time in writing. Yes______ No_______

Groove Fitness Studio LLC Registration/Release  
Groove Fitness Studio LLC Registration/Release  

Please print, fill out, and sign a registration/release document for each attendee.