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WAIVER

Please fill out and digitally sign this waiver before coming to your first class.

First Name

Last Name

Email Address

Date of Birth

Please specify anything we should know about (e.g. injuries, experience level etc.)

Have you lost your consciousness in the last past 12 months?

No

Yes

Initials

Today's Date

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I declare that the informat I have provided is accurate & complete

Thanks for submitting!

CONTACT US

48 E. Park Ave
Long Beach NY 11561

Jake@southsidemt.com ( Hearing Impaired. Text or email preferred.)

Mike@southsidemt.com

(212)710-8914

Thanks for submitting!

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