Employee Wellness Fitness Class
Release and Waiver of Liability
Fitness Class: _______________________________________________________________________
Name: ________________________________________ Date of Birth: __________________
Phone Number: _________________________________
Email Address: __________________________________
Emergency Contact Name: ________________________
Emergency Contact Phone: ________________________
To the best of my knowledge, information and belief, I have no physical restriction which would prohibit
my participation in this fitness class sponsored by the Elizabethtown College Employee Wellness
I understand that I am responsible for monitoring my own condition throughout the exercise program
and should any unusual symptoms occur, I would cease my participation and notify the instructor of the
In signing this consent form, I acknowledge that I have read this waiver of liability and fully understand
its terms. I agree to accept the risk of such exercise and further agree to not hold Elizabethtown
College, the Employee Wellness Committee members, or the fitness instructors conducting the class
liable for any and all claims, suits, losses or related cause of action for personal injuries or damages that
may arise out of my participation.
Name (please PRINT) _____________________________________________ Date: _______________
Name (please SIGN) ______________________________________________ Date: _______________
1) Before beginning this exercise program, it is strongly recommended that you consult your
2) Any other concerns the instructor should know before you start, please list below*.
*The Employee Wellness Team and/or fitness instructor reserve the right to request a Physicians’
authorization / permission.