EEK Fitness, Inc.
P.O. Box 185 San Jacinto, CA. 92581
PLEASE PRINT
PARTICIPANT’S NAME:
__________________________________________________________
STREET ADDRESS:
__________________________________________________________
CITY: _________________________________________
ZIP CODE: ________________
DATE OF BIRTH: ____________
HEIGHT: _______
WEIGHT: _______
SEX: _______
DISABILITY___________________________________________________
OTHER HEALTH
CONDITIONS__________________________________________________
PARENT(S)
NAME________________________________________________________
HOME PHONE #: ____________________
WORK PHONE#:_____________________
ALTERNATE CONTACT IN CASE OF EMERGENCY:
NAME: ____________________________
PHONE NUMBER: _______________________
E -MAIL
ADDRESS__________________________________________________
Dates and Times: Fridays
March 2 – April 27, 2012
Physical Rehab and Aquatic Center of Hemet
4000 E. Florida Ave Suite A
Cost: $25
WAIVER AND HOLD HARMLESS – Every effort is made to provide participants with a
safe, enjoyable, and memorable experience. I attest and verify that my child is physically
able to participate in all activities offered at EEK Fitness, Inc. I understand, however, that
there are inherent risks in outdoor and camp-related activities and travel to and from the
site, and, knowing the risks, nevertheless, I agree to ASSUME ALL RISKS OF PERSONAL
INJURY, PERMANENT, TEMPORARY, TOTAL OR PARTIAL DISABILITLY, DISFIGUREMENT,
PARALYSIS AND ANY OTHER LOSSES OR DAMAGE TO PERSON OR PROPERTY OR DEATH,
sustained while my child participates in, attends, prepares for or travels to and from EEK
Fitness, Inc., including the risk of negligence of the EEK Fitness, Inc. staff, or hidden, latent
or obvious defects in the facilities or equipment used. I agree if any claim for personal injury
or wrongful death is commenced against EEK Fitness, Inc. (including its officers, directors,
members and/or volunteers), I will defend, indemnify and hold harmless EEK Fitness, Inc.
from any and all claims or causes of action for personal injuries, property damage or
wrongful death that hereafter accrue, arise out of, result from, or are caused directly or
indirectly by my child’s attendance at EEK Fitness, Inc.’s swim program. I have read and I
understand this Waiver and Hold Harmless provision.
Participant’s name: ________________________________
Signature: ________________________________________ (if over 18)
Parent’s name: _____________________________________
Parent’s signature: __________________________________ (if under 18)