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Private Classes & First Free Class
Single & Class Pack Purchases

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Private Instruction Classes 
First Free Class
Single & Class Pack Purchases

Complete this form if:

  1. You are not a member and you are participating in a private instruction class.

  2. You are not a member and you are redeeming your first free class. 

  3.  You are not a monthly/yearly member and have purchased single classes, or multiclass packs. 

2026 RELEASE OF LIABILITY

Private Class Instruction, First Free Class Participants

&

Single Class & Class Pack Participants

Personal Information

Birthday
Month
Day
Year
Multi-line address

Emergency Contact

CONSENT AND AGREEMENT

Risk Acknowledgement: I understand that health or fitness club activities involve known and unanticipated risks which could result in physical or emotional injury, paralysis, or permanent disability, death, and property damage.

Risks include, but are not limited to, musculoskeletal injuries, broken bones, and/or overuse injuries, injuries caused by equipment that breaks or otherwise fails; death as a result of drowning or brain damage caused by near drowning; medical conditions resulting from physical activity; and damaged clothing or other property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity.

Assumption of Risk: I acknowledge and expressly accept and assume all of the risks inherent in this activity or that might have been caused by the negligence of the Releasees. My participation in this activity is purely voluntary and I elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation.

Open Gym 24/7 & Pilates on Demand Access: I understand that I am using a 24/7 facility and there will be no supervision or assistance during my workout, especially outside of staffed hours.

Waiver of Liability: I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from negligence. This release does not apply to claims arising from intentional conduct.

Attorney Fees: Should Releasees or anyone acting on their behalf be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

Insurance: I represent that I have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume - and bear the costs of - all risks that may be created, directly or indirectly, by any such condition.

Lawsuits: In the event that I file a lawsuit, I agree to do so solely in the state where Releasees' facility is located, and I further agree that the substantive law of that state shall apply.

I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By signing this document, I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.

I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain.

Privacy Policy

Confidentiality Commitment: I acknowledge that Destination Wellness commits to maintaining the confidentiality and privacy of all personal information provided in this form. Information will only be used to evaluate suitability for fitness services use and manage my experiences appropriately.


Data Usage: I consent to the collection, use, and, where necessary, the disclosure of my personal information as needed for the provision of fitness services. This may include sharing information with healthcare professionals under circumstances that require medical intervention.

Rights to Access and Correction: I understand that I have the right to request access to my personal records held by the facility and can request corrections to any inaccuracies in my personal data.


Security Measures: I acknowledge that the facility implements appropriate security measures to protect my personal data from unauthorized access, alteration, or destruction.

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Date and time
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Destination Wellness

31 W Church Street

Newark, OH 43055

(740) 280-2031

lcdestinationwellness@gmail.com

www.lcsdestinationwellness.com

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