EFTA00522224.pdf

pure barre 1237 Second Ave New York, NY 10065 CLIENT INTAKE Participant and/or Parent/Guardian Name: Karyna Shuliak Date of Birth: Email: Phone: Street Address: 301 E 66th Street City: New York State: NY How did you find out about us? If a friend, please name! *Do you want to receive text message alerts? 0 YES ® NO If Yes, who is your mobile provider? Zip Code: 10065 HEALTH INQUIRIES & EMERGENCY CONTACT INFORMATION *Do you have any injuries/health issues? O YES ONO If yes, please describe: *Are you pregnant? O YES ONO If yes, when is your due date? *Emergency Contact Name: *Relationship: Sue friend *Phone: (917) 971-2459 EXERCISE INSTRUCTION AND REPRODUCTION *Are you currently or were you previously an exercise instructor or trainer of any kind, including but not limited to Pilates, yoga, dance, aerobics or any type of athletics and fitness? O YES ONO *Are you prnfecsinnally affiliated with any establishment that is involved with exercise, fitness, athletics, nutrition or any other similar or related field? O YES ONO If YES, please indicate company(s): Please read and sign the following: I will not teach or reproduce in any way any of the exercises, movements, class formats, choreography or music compilations from this studio, its' agents or employees, or materials affiliated with it. I understand that any violation of this will be enforced to the maximum extent permitted by EFTA00522224 law and will include, but not be limited to, injunctive relief, actual and punitive damages as well as attorney fees. Client or Parent/Guardian Signature: Policies and Procedures Cancellation/No Show Policy: I understand that I am required to cancel 12 hours prior to the start of class for classes before noon. Classes after 1 pm I am required to cancel 6 hours prior. Cancelling after the 12 hours window for classes before noon and after the 6 hour window for classes after 1 pm is considered a Late Cancel, and my credit card will be charge a Late Cancel Fee of $20 (for unlimited packages) or lose my class (for class packages). I understand that not showing up to class without cancelling is considered a No Show and I will be charged $20 (for unlimited packages) or lose my class (for class packages). I understand that the cancellation policy is subject to change. INITIAL HERE: ks Talent Release: I authorize Pure Barre Upper East Side Second Ave & 65th to use my picture, name, statements and likeness without charge, for promotional purposes in advertising, video, web, and new media. RELEASE AND INDEMNITY AGREEMENT THIS RELEASE AND INDEMNITY AGREEMENT ("Release") is made by the undersigned adult (the "Participant"), to release and indemnify Sweat Equity, LLC, a New York limited liability company, and all of its respective members, employees, heirs, successors, agents, contractors and assigns as set forth below. Participant, on Participant's own behalf and on behalf of the other members of the Participant's family, including Participant's spouse, parents, children, heirs, and assigns, (singularly and collectively referred to as "Participant") hereby grants to the Institute this full release and indemnification as consideration in exchange for permitting Participant to participate in this exercise program. Participant is entering into this Release after having viewed or having the opportunity to view the studio; having reviewed the instructor's qualifications; having had the scope of the services and associated risks explained; and having had an opportunity to ask questions regarding the services and risks associated with this exercise program. Participant is voluntarily participating in the activity with full knowledge, understanding and appreciation of the risks inherent in any physical exercise and expressly assumes all risks of injury and even death which could occur by reason of participant's participation. EFTA00522225 Participant releases Pure Barre Upper East Side Second Ave and 65th from any liability and agrees not to sue the Institute with respect to any cause of action for bodily injury, property damage, or death occurring to participant as result of participating in this exercise program. Participant hereby assumes full responsibility for risks of bodily injury, property damage or death to participant due to the ordinary negligence or gross negligence of the Institute and the ordinary negligence, gross negligence, or willful misconduct of any third party including others participating in the exercise program. Participant agrees to indemnify, defend, and hold harmless, at Participant's sole cost the Institute from any and all claims arising out of Participant's participation in the exercise program. All personal property brought to the Institute is brought at the sole risk of the Participant as to its theft, damage, or loss. Participants agree to opt-in for email notifications and alerts. Participant will follow the dress code set by Pure Barre including wearing pants- leggings or capris (no shorts), a top that covers the midriff and socks. Participant understands that their credit card is securely stored in their client profile and will be charged with their consent for purchases. Participant understands the late cancel policy and their credit card will be charged if they violate the policy. Participant expressly agrees that the terms of release indemnity contained herein are intended to be as broad and inclusive as is permitted by the laws of New York. Any provision of this Release found to be invalid by the courts having jurisdiction shall be invalid only with respect to such provision or portion. Participants must be 16 years of age. Any participant under the age of 18 must have a parent or legal guardian sign on their behalf. CONFIRMATION OF LATE CANCEL POLICY I give permission to Sweat Equity, LLC to charge my credit card on file in accordance with the cancellation policy. PARTICIPANT HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND INDEMNITY AGREEMENT. Adult Participant and/or Parent/Legal Guardian of Minor: First Name: Kamm Last Name: Shuliak Birth Date: State: Address: City: Postal Code: 10065 Email: Phone: Legal Signature of Adult Participant or Parent/Guardian if a minor participant(s): EFTA00522226 Date and rime Signed: 10/08/2017 at 10:24 System Time Stamp: 10/08/2017 at 2:20 EFTA00522227