Membership Signup

Name of 1st Person *

First Name

Last Name

Birthday of 1st Person *

MM

DD

YYYY

Name of 2nd Person

First Name

Last Name

Birthday of 2nd Person

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

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Cell Phone

(###)

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Home Phone

(###)

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Emergency Contact Cell Phone

(###)

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Loose Center - Liability Waiver *

I understand that there are risks of injury involved in participating in any Loose Senior Citizen Center exercise class or other exercise program or activity. I voluntarily assume the risk for any harm, injuries, or damages that I may sustain as a result of my participation in any exercise class, program, or activity. I certify that I am in good physical condition and that I am able to safely participate in the exercise class, program, or activity and to safely utilize any of the exercise equipment at the Loose Senior Citizen Center.

I am aware that none of the instructors at the Loose Senior Citizen Center maintain liability insurance coverage for any claims that might be asserted by participants against an instructor for injuries received in participating in a Loose Senior Citizen Center exercise class, program or activity.

I release the Loose Senior Citizen Center, its instructors, officers, directors, employees, volunteers, agents, representatives, successors, and assigns, from any and all liability for injuries, damages, or expenses resulting from my participation in any Loose Senior Citizen Center exercise class, program, or activity. This release is binding on my heirs, assigns, executors, ad- ministrators, and representatives.

I Agree

I Decline

Photo Release *

I grant to Loose Senior Center, the right to take photographs of me and my family in connection with any Loose event. I au- thorize the Loose Center its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Loose Senior Center may use photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

I Agree

I Decline

Exercise and Equipment Usage Consent Form *

Because physical exercise can be strenuous and subject to risk of serious injury, the Loose Senior Citizen Center (LSCC) urges you to consult with your doctor before using any exercise equipment or participating in any exercise activity at LSCC.

I understand that there are risks of injury involved in using any exercise equipment or participating in any exercise activity at LSCC. I voluntarily assume the risk for any harm, injuries, damages, or expenses that I may sustain as a result of my usage of any exercise equipment or participation in any exercise activity at LSCC. I understand that any medical treatment resulting from injuries that I sustain due to my usage of any exercise equipment or participation in any exercise activity at LSCC is my sole responsibility.

I certify that I am in good physical condition and that I am able to safely use any exercise equipment and to safely participate in any exercise activity at LSCC that I choose.

I release and hold harmless the Loose Senior Citizen Center, its instructors, officers, directors, employees, volunteers, agents, representatives, successors, and assigns, from any and all liability for injuries, damag- es, or expenses resulting from my use of any exercise equipment or my participation in any LSCC exercise activity. This release is binding on my heirs, assigns, executors, administrators, and representatives. This release includes any injuries, damages, or expenses resulting from the malfunction of any equipment, or the actions or failure to act of any individual providing instruction, maintenance, or supervision of any exercise equipment or exercise activity at LSCC.

I acknowledge I have carefully read this Exercise and Equipment Usage Consent Form and that I fully un- derstand and agree to its contents. I understand that I am giving up the right to bring legal action against LSCC for any harm, injuries, damages, or expenses that I may sustain as a result of my usage of any exercise equipment or my participation in any exercise activity at LSCC.

I authorize the Loose Senior Citizen Center to record my image and voice, and I give LSCC and all persons or entities acting pursuant to authorization from LSCC the right to use these recorded images and voice. I understand that said images and/or voice will be used for educational, advertising and promotional pur- poses in conventional and electronic media, including but not limited to the internet, and any future me- dia, and in any printed material in connection therewith. I understand and agree that these images and recordings may be used, duplicated, and distributed in any form or manner without compensation to me. I release LSCC, its instructors, officers, directors, employees, volunteers, agents, representatives, succes- sors, and assigns, from any liability relating to the use, duplication, or distribution of these images and recordings.

I Agree

I Decline