Cory Czepa Liability Waiver Waiver & Assumption of Risk Dynamic Waiver to Participate in Live 2 B Healthy®️Programs Legal Name(Required) First Last Birthdate(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address(Required) Street Address City State / Province / Region ZIP / Postal Code Email (optional)For communication of class changes/updates Phone (Optional)Please provide a phone number to receive text messages regarding changes in schedule (sick trainer/class cancellations/etc.)Health Insurance Provider: Does your Health Insurance include Wellness or Fitness Benefits?(Required) Yes No Qualifying Plan Benefits SilverSneakers Silver&Fit Renew Active by United Healthcare UCare One Pass Enter SilverSneakers Number16 digits Find your number: https://tools.silversneakers.com/Eligibility/CheckEligibility Enter Silver&Fit NumberCheck Eligibility/obtain code: https://www.silverandfit.com/Enter Renew Active Number10 Digits Member Code starting with A To obtain your code, please call the customer service number on the back of your insurance card. Enter One Pass Number10 Digits Member Code starting with A To obtain your code, please call the customer service number on the back of your insurance card. https://www.partneroptumfitness.com/Today's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature(Required)Sign using either mouse or stylus
