Program Form

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Personal Contact Information
**All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. **
Name *
Write your name
Date of Birth *
Address *
Your Address
Phone *
Your Phone
Email *
Your Email
Occupation
Your occupation
Emergency Contact Information
Name *
Write the name of your emergency contact
Relation *
Phone *
Momentum Health & Wellness Waiver and Release of Liability
Every participant must read and understand this Waiver and Release of Liability form prior to participating in the Program.


  1. I wish to participate in the exercise and training program(s) offered by Momentum Health & Wellness. I understand and acknowledge that there may be inherent risks, hazards or dangers associated in participating in these program(s), any of which could result in my sustaining personal and/or bodily injury to myself and/or my child(ren). I agree that Momentum Health & Wellness shall not be liable or responsible for any injuries to me and/or my child(ren), resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Momentum Health & Wellness, her company’s owners, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program(s). This Release shall be binding upon my heirs, executors, administrators and assigns.
  2. I understand that it is my responsibility to consult my health care provider prior to and regarding my participation in the program(s), offered through Momentum Health & Wellness.
  3. I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during the program (s). I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Instructor(s).
  4. If a session is missed for any reason, it is non – refundable and non – transferable.
  5. I understand that Momentum Health & Wellness may photograph some of their events/sessions and I provide written approval for them to use these pictures for promotional purposes.


I have read this Waiver and Release of Liability and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.

Type your name *
By typing your name above, you are electronically certifying this waiver document just as if you would physically sign it if it was on paper.
Date *
Cost *

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