Name *

First Name

Last Name

Please check only YES or NO if any of the following questions apply to you: Has your doctor ever said that you have a heart condition and should only do physical activity recommended by a doctor?
 Do you feel pain in your chest when you do physical activity? In the past month, have you had chest pain when not doing physical activity? Do you lose balance due to dizziness or do you ever lose consciousness? Please note that if you answer yes to any of the above, I recommend that you speak with your physician before beginning any new exercise program. *

Yes

No

Do you know of any other reason why you should NOT do any physical activity? Please note that if you answer YES, I recommend that you speak with your physician before beginning any new exercise program. *

Yes

No

I understand that this movement program does not provide diagnostic information and is not meant to substitute for medical treatment by a healthcare practitioner.
I have informed Tracy Renee Stafford about my state of health and I have transmitted any recommendations and restrictions on the part of my healthcare practitioner insofar as this movement program is concerned *

Yes

No

I have read the privacy policy and the terms of conditions on the website tracyreneestafford.com, and understand that for group classes, there is a 1 hour cancellation policy, and unused classes cannot be refunded but can be transferred. For 1-to-1 classes/sessions, I understand that there is a 24 hour cancellation policy, and that refunds may be issued for unused classes/sessions at the discretion of the business. Please note: your information will NEVER be shared to a 3rd party for promotional purposes. *

Yes

No

WAIVER AND RELEASE OF LIABILITY In consideration of the risk of injury while participating in “Online Movement Classes with Tracy Renee Stafford” (the "Activity"), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, or my representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge Tracy Renee Stafford, and her representatives, for any physical, psychological, emotional or economic loss or injury, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity. I am voluntarily participating in the aforementioned activity entirely at my own risk. I am aware of the risks associated with participating in this activity. I understand that these injuries or outcomes may arise from my own or others' negligente, or the condition of the activity location(s). Nonetheless, I assume all risks, both known or unknown to me, of my participation in this activity. I agree to indemnify and hold harmless Tracy Renee Stafford against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If Tracy Renee Stafford incurs any of these types of expenses, I agree to reimburse her. I acknowledge that Tracy Renee Stafford and her representatives are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Tracy Renee Stafford. I ackowledge that this activity may involve a test of a personas physical and mental limits and may carry with it the potential for death or serious injury. I acknowledge that I have carefully read this "Waiver and Release" and fully understand that it is a release of liability. I expressly agree to release and discharge Tracy Renee Stafford and her representatives, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring legal action against Tracy Renee Stafford for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Tracy Renee Stafford, its agents, and employees. In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. *

YES

Please sign me up for your email list! (Monthly newsletters, & occasional news about new products & offers only. Your info will never be shared or sold). *

Yes

No