Name____________________________________________________________________

Address__________________________________________________________________

Town State Zip___________________________________________________________

Daytime Phone___________________________________________________________

Evening Phone___________________________________________________________

Email____________________________________________________________________

I have enrolled in a program of strenuous, physical activity including but not limited to aerobic, weight training and various aerobic conditioning machinery offered by Jay Lally Performance Training facility. I hereby affirm that I am in good physical condition and do not suffer from any disability which would prevent or limit my participation in this exercise program. In consideration of my participation in this exercise program, I _______________________________, for myself, my heirs and my assigns, hereby release Jay Lally Performance Training, from the claims, demands and causes of action arising from my participation in the exercise program. I fully understand that I may injure myself as a result of my participation in the exercise program and I hereby release Jay Lally Performance Training and staff from any liability now or in the future including but not limited to heart attacks, muscles strains, pulls or tears, broken bones, shin splints, heat prostration, knee / lower back / foot injuries and any other illness, soreness or injury however caused occurring during or after my participation in the exercise program.

I hereby affirm that I have read and fully understand the above.

Client Signature_________________________________________________________

Date___________________________________________________________________

Parent or Legal Guardian Signature if Minor/Date
 
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