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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

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Date and time
Month
Day
Year
Time
HoursMinutes

Destination Wellness

31 W Church Street

Newark, OH 43055

(740) 280-2031

lcdestinationwellness@gmail.com

www.lcsdestinationwellness.com

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