New Heights

Application and Release For Adults

Name______________________________________________________

Home Phone __________________ Cell Phone ____________________

Email: _____________________________________________________

One or More Emergency Contacts:

Name: ________________________________ Relationship___________

Home Phone __________________ Cell Phone ____________________

Email: _____________________________________________________

Name: ________________________________ Relationship___________

Home Phone __________________ Cell Phone ____________________

Email: _____________________________________________________

Release of Liability: I am at least 18 years old and I hereby declare that I am

physically able to participate in physical fitness exercises and activities. I understand

that it is advisable for me to contact my physician prior to starting an exercise program.

In the event that I am injured, I waive and release all rights to any claims for

damages for myself and any heirs against New Heights, sponsors, or representatives.

I understand that New Heights does not carry medical insurance for participants

or coaches and I am fully responsible for any and all medical bills.

Medical Release: I am at least 18 years old and in the event that I suffer sudden illness,

accident, or injury, and my emergency contacts are not available and cannot be reached,

I give permission that medical and emergency personnel be contacted to provide medical

and emergency treatment. I understand that I am fully responsible for any and all cost for

medical and emergency treatment.

List pertinent medical information or physical limitations below

and alert coaches to any serious ailments or concerns (diabetes,

allergies, asthma, etc.):

By signing this form, you are agreeing to all the statements listed above,

including, but not limited to, release of liability and medical treatment.

Please Sign and Date:

_________________________________________ _______________

Signature Date