Empowered for Birth On-Demand Workshop

Pre-Registration

Thank you for signing up!

Please fill out this form to complete your pre-registration.

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

Zip Code *

Emergency Contact Person *

Emergency Contact Person's Phone Number *

I am cleared by a physician to exercise. *

yes

I have some restrictions

Do you require any adaptations specific to injuries or other physical limitations?

If Pregnant, when is your due date?

Do you take any medications that would alter your heart rate or blood pressure? *

Yes

Do you have any chronic health conditions, injuries, prior surgeries, or any other health- related info that your personal trainer/instructor should be aware of? *

By checking the box below, I agree to assume full responsibility for any risks, injuries, or damages, known and unknown, which might occur as a result of participating in movement activities with Emily Pareti, and Cheryl Klugmann, and Create Your Core LLC, Jennifer Penn. I voluntarily agree to waive any claim/ suit related to personal injury or damages related to participating in classes/ workshops. I agree to purchase terms and cancellation policies released at check out. I am cleared by a physician to exercise and statements about my need to know health condition/s are provided. I have carefully read this waiver of liability and understand that I am giving up legal rights, including my right to sue. I acknowledge that I am signing this waiver freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability to the extent allowed by law. *

I confirm and agree to the statement above.

I am authorizing Create Your Core, LLC, and its employees, agents, and authorized representatives, to use and/or disclose any photographs, videos, and/or audio recordings for the following purposes: Use in internal and external advertising, marketing, public relations or collateral materials, including but not limited to posting on Create Your Core, LLC’s website and social media sites, use in news releases or stories, including television, newspaper, radio broadcasts, and social media sites, use in internal and external education and/or training programs for the public and/or medical professionals, including but not limited to use on public websites and social media sites.

ONLY check this box if you DO NOT authorize Create Your Core LLC to use and/or disclose any photographs, videos, and or audio recordings for the above mentioned.

Participant Signature *

Clear

Date *