Waiver & Assumption of Risk Waiver to Participate in Live 2 B Healthy Programs Class Location(Required) Please use this space to indicate where the class your are registering for is being held.Franchise Location(Required)L2BH of Des MoinesL2BH of East DenverL2BH of Eastern SDL2BH of East IowaL2BH of North DallasL2BH of North DenverL2BH of North Central MinnesotaL2BH of North MinneapolisL2BH of North MinnesotaL2BH of North San DiegoL2BH of NE IowaL2BH of NW IowaL2BH of SE IowaL2BH of SW IowaL2BH of South MinneapolisL2BH of SE MinnesotaL2BH of SW MinnesotaL2BH of PhoenixL2BH of Walnut Creek CAL2BH of West DenverLegal Name(Required) First Last Birthdate(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Consent(Required) The Class Participant agrees to the followingI acknowledge that I have voluntarily chosen to participate in one or more physical exercise or fitness activity or sport programs (“Programs”). I am fully aware of everything that is involved in the Programs, whether offered live or on-line, including the actions and activities I will be required to perform while participating in the Programs. I acknowledge (i) the nature of the risks of particular Programs in which I have chosen to participate and (ii) the strenuous nature of those Programs. I understand, among other things, the risks associated with physical injury, infectious diseases (including Covid-19), abnormal blood pressure, heart attack and even death, as well as the risks associated with any organization or individual involved in providing or promoting any classes, functions, Programs, testing, or other activities in which I participate. I expressly acknowledge that I have consulted my physician before deciding to participate in the Programs or I have voluntarily chosen not to consult with my physician even though I have been advised to do so. In the event that my physician has recommended any limitations to my physical activity or I have experienced any of the following conditions, I hereby attest that I have informed my physician of the condition(s) and have obtained express consent from my physician to participate in the Programs. • Chest pains while at rest and/or during exertion, previous heart attack, or high blood pressure • Any heart or circulatory conditions, such as vascular disease, stroke, chest pain, congestive heart failure, poor circulation to the legs, valvular heart disease, blood clots • Frequent fast, irregular heartbeats OR very slow heartbeats • Diabetes • Previous hip or spinal fracture (as an adult) • Lung disease or shortness of breath after mild exertion, at rest, or in bed • Open cuts on my feet that do not seem to heal • An unexplained weight loss ten (10) pounds or more in the past six (6) months • More than 2 falls in the past year (no matter what the reason) • More than one year since I have engaged in regular physical activity By signing this document, I expressly assume all risk for my health and well-being and expressly assume all other risks associated with participating in the Programs, including, but not limited to, the negligence of any organization or individual participating or involved in providing or promoting any of the Programs or any other classes, functions, testing, or other activities related to the Programs. I also hereby release, waive, discharge and covenant not to sue any provider, supplier or promoter of the Programs and any class instructor and any individual or entity providing, promoting or involved with the Programs or any other classes, functions, testing, or other activities related to the Programs in which I participate at any time, whether live or on-line, from any and all claims, lawsuits, demands, liabilities, losses, or damages (including death, bodily injury or damage to property) caused or alleged to be caused in whole or in part by the negligence of any of the foregoing individuals or entities. I have read and understand this waiver and express assumption of risk. I have also read, understand, and will adhere to all guidelines and policies in regard to the Programs in which I chose to participate. This waiver and release shall survive the term of any agreement related to such Programs.Consent(Required) The Class Participant agrees to the followingUse of Personal Information, Image, Likeness, and/or Voice: We may photograph, record on audio or video, or otherwise record Live 2 B Healthy classes. In exchange for your use of the class or your participation in any Live 2 B Healthy Senior Fitness class (whether in community, outdoors, or otherwise), you understand, acknowledge, and agree that you may be photographed, recorded on audio or video, or otherwise recorded and hereby agree and consent for all purposes to the sale, reproduction, and/or use in any manner of any such photograph, audio, video, or other recording or depiction of your likeness and/or voice whatsoever by us, any Live 2 B Healthy Franchisee, and any nominee or designee of us or them, including without limitation any agency, client, periodical or other publication, in all forms of media, whether now or hereafter devised, throughout the world and in perpetuity, and in all manners, including without limitation advertising, trade, display, editorial, art, and exhibition. You further understand and agree that any such photograph, audio, video, or other recording or depiction of your likeness and/or voice may be modified, altered, cropped, and combined with other content such as images, video, audio, text, and graphics, and hereby waive any right that you may have to inspect or approve any finished image, video, or audio containing a depiction of your likeness or voice. You further agree that the Class, any other Classes, and/or the Live 2 B Healthy Vendor Parties (defined herein), may use any information gathered in this form or through your use of the class or participation in any Live 2 B Healthy Senior Fitness class, provided the information does not personally identify you or provide facts that could lead to your identification, for any purpose, including without limitation research, product and program improvements, and statistical purposes. You agree to hold harmless and indemnify the class, any other Live 2 B Healthy Franchisee, and the Business Parties (defined herein), from and against any and all liability, damage, loss, and/or claims of any kind or nature whatsoever, including, without limitation, any and all claims and demands relating to libel, invasion of privacy, and violation of publicity rights.Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmailFor communication of class changes/updates. Email Consent By checking this box you agree to receive emails from Live 2 B Healthy Senior Fitness.For more info see https://live2bhealthy.com/privacy-policy/PhonePlease provide a phone number to receive text messages regarding changes in schedule (sick trainer/class cancellations/etc.)Texting Consent By checking this box you agree to receive text messages from Live 2 B Healthy Senior Fitness.For more info see https://live2bhealthy.com/privacy-policy/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/CheckEligibilityEnter 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)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature(Required)Sign using either mouse or stylusPhoneThis field is for validation purposes and should be left unchanged.
