Exercise Class Sign Up & Waiver Form

2. First Name
3. Last Name
5. Email
6. Phone
8. Address
10. City
11. State
12. Zip Code
14. Register for Classes

    Let us know which classes you will be participating in (select all that apply)

    1. Pilates Classes on Tuesdays at 7:30 pm
    2. Pilates Classes on every other Thursdays at 7:30 pm
    3. Gentle Yoga on Fridays at 9 am
    4. Gentle Yoga on Wednesdays at 9:30 am

    1. Yoga on Mondays at 5 pm
    2. Tai Chi on Mondays at 6 pm
    3. Zumba Gold on Mondays at 9:30 am
16. Waiver Release

    1. I have read the Media Borough waiver and release of liability and assumption of all risks and agree to the terms stated
    2. I prefer to print and sign the paper waiver and bring it to class

    View the Waiver Form (PDF).

18. Waiver and Release of Liability and Assumption of All Risks

    Read before checking the box for waiver release

    By checking the waiver release box, I agree that:

    I have voluntarily decided to participate in activities and events at, and use the facilities of the Recreation Board of the Borough of Media.

    This form is an important legal document.  It explains the risks you are assuming by beginning an exercise program.  It is critical that you read and understand it completely.  After you have done so and you wish to participate in the activity, please check the box above saying that you have read and agree to the terms.

20. Waiver and Covenant Not to Sue

    I have volunteered to participate in an exercise program run by the Recreation Board of the Borough of Media or a third-party instructor/ contractor of the Recreation Board at the Media Borough Hall, which will include, but may not be limited to, weight and/or resistance training, and aerobic activity. I am voluntarily participating with the knowledge of the numerous risks and dangers involved, including but not limited to: physical exertion for which I may not be prepared, breakdown of equipment, whether rented or owned; accident or illness; the risk of negligence by myself or others, including the Recreation Board or its instructors/contractors and the potential for serious injury, including permanent paralysis or death.

    In consideration of using the Borough of Media facilities for this program run by the Recreation Board, to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless, release and discharge forever the Recreation Board of the Borough of Media and the Borough of Media, and their respective officers, officials, agents, contractors, heirs, assigns, consultants and/or employees, sponsoring agencies, sponsors, advertisers, and the owners and the lessors of the premises used to conduct a Recreation Board of the Borough of Media related event from and against any and all claims, liability, demands, damages, rights of action or causes of action, present or future, arising of or connected with my participation in this or any exercise program including any injuries resulting there from, including, without limitation, any claim relating to exposure to the Covid19 virus or any variants thereof.

    This release shall be legally binding upon me personally, all members of my family and all minors accompanying me, my heirs, successors, assigns and legal representatives, it being my intention to fully assume all of the risks associated with my use of the facilities of the Borough of Media and the Recreation Board of the Borough of Media, and to release from any and all liabilities associated with my use of the facilities to the maximum extent permitted by law.

    I understand that the Recreation Board of the Borough of Media reserves the right to refuse admittance to any person who refuses to sign this waiver or who it judges to be incapable of meeting the rigors, requirements and safety requirements for participation in the activities.

22. Assumption of Risk

    I recognize that exercise might be difficult and strenuous and that there could be risk inherent in exercise for some individuals and I understand that I should contact my physician or other qualified medical specialist prior to beginning this program in order to determine if such physical activity is safe for me to undertake.  I acknowledge that the possibilities of certain physical changes during exercise do exist.  These changes include musculoskeletal injuries, abnormal blood pressure, fainting, disorders in heartbeat, heart attack, and in rare instance, death.

    If I experience any pain or discomfort during the workout session, I will immediately inform the staff. I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of or occurs.  Because various exercises are contraindicated (should not be done) under certain medical conditions, I affirm that I have stated all known medical conditions and understand that there shall be no liability on anyone’s part should I forget.  In any event, I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate.

    In the event of the need of medical attention, I authorize the officials of the Recreation Board to use their best discretion to have me transported to a medical facility and I will take the responsibility for such actions.

    I represent that I have read and understand this consent and release and acknowledge that this release is being relied on by the Recreation Board of the Borough of Media and the Borough of Media permitting me to participate in their facilities. 

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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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