Minor Consent Form

Parent's Name *

Address *

Phone *

Cell Phone

Doctor *

Doctor's Phone Number *

Closet Family Relative Name *

Relative's Phone Number *

Emergency Name *

Emergency Name Phone Number *

Work Phone Number

Minor's Name *

Birthdate *

Age *

Allergies/Medical Disorders

Minor's Name (2)

Birthdate (2)

Age (2)

Allergies/Medical Disorders (2)

Minor's Name (3)

Birthdate (3)

Age (3)

Allergies/Medical Disorders (3)

Medical Release *

As the parent, agency representative, or legal guardian, I hereby give consent to In Motion Fitness to provide emergency medical or dental prescribed by a duly licensed physician (MD) or dentist (DDS) for the above named minors. This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependant (s).

I (We) the undersigned understand In Motion Fitness’ policy and supervision requirements regarding children under the age of 18 years as stated in the Club rules, policies and guidelines. By signing an In Motion Fitness minor consent form, I realize that I am responsible for the financial obligation of the above named child (ren) while the child (ren) are in the Club or on a Kids In Motion field trip. Should disciplinary action cause temporary expulsion or suspension of Club privileges, I am still responsible for monthly financial obligation.
Waiver of Claim *

The use of IMF’s equipment and facilities may be hazardous and could result in personal injury, accidents or death. Facilities may have wet surfaces and if members and/or guests do not use caution, a slip or fall could result. The member expressly agrees that all use of IMF facilities, exercise equipment and any transportation provided by IMF is undertaken by the member or member’s guest at his/her sole risk. The member further agrees that IMF is not liable for any injuries or damages to any member or guest or the property of any member or guest. The member agrees that IMF is not subject to any claim, demand, injury or damages whatsoever, including, without limitation, those damages resulting from acts of active or passive negligence on the part of IMF, it’s owner, officers, agents or employees. The member for himself/herself and on behalf of his/her heirs, assigns and successors, does hereby expressly forever release and discharge IMF, it’s owner, officers, agents, or employees, assignees, and successors from all such claims, injuries or damages, actions or cause of action. The member agrees that IMF is not responsible or liable to member’s or their guests for articles damaged, lost or stolen in or about IMF, or in lockers, or for loss or damage to any property including, but not limited to, automobiles and the contents thereof.

By entering your email address you are agreeing to the terms and conditions contained in this document.

Email Signature *

Date of Consent *