PERSONAL INFORMATION Name: Date of Birth: Address: City/State/Zip: EMERGENCY CONTACT Name: Phone: Relationship to Emergency Contact: LIABILITY WAIVER I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with Fixology Fitness LLC. Having such knowledge, I hereby release Fixology Fitness, their representatives, agents, and successors from liability for accidental injury or illness that I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program. I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program. PHOTO RELEASE I, hereby consent and agree that Fixology Fitness, it’s employees , or agents have the right to take photographs, videotape, or other digital recordings of me exclusively for the purpose of advertising, marketing, and/or website content. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I understand that there will be no financial or other remuneration for said media. Date: Signature: INTAKE DETAILS Height: Weight: Age: Injuries, surgeries, pertinent past medical history and any medications: