Waiver of Liability and Informed Consent Release

I wish to participate in a fitness program which will be designed and administered by a representative of Kaita Mrazek DBA The Listening Movement based upon what they, in their professional judgment, think is appropriate. I understand my participation in this program is voluntary, and that I am free to deny consent in the program at any time.

It is my desire to participate in the exercise program offered by Kaita Mrazek and it is with full appreciation of the various hazards and risks associated with this work that I do so. I understand that there is a risk of certain unpredictable changes and physical responses that can occur during or following an exercise session.

In light of these potential risks, I understand that it is important for me to inform Kaita Mrazek of all physical limitations and prior medical conditions which may affect my participation in this exercise program or which may be affected by my participation.

Below, I list all medical conditions and injuries that may affect my participation, as well as the doctors who treated or are continuing to treat me.

Please check below to acknowledge that you have read and understand our agreement

I acknowledge and understand that I should stop exercising immediately if I detect any discomfort of any sort during the course of this exercise program.

I understand that there is a 24-hour cancellation policy for all appointments that I make with Kaita Mrazek.

Name

First Name

Last Name

Date

YYYY

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