_________________________________________
(Location Name)
_________________________________________
(Location Address)
First Name: ___________________________________________________
Last Name: ___________________________________________________
Phone: ______________________________________________________
Email Address: ________________________________________________
Birthday: ____________________________________________________
Emergency Contact Name: _____________________________________
How did you hear about us: ____________________________________
Address 1: ___________________________________________________
Address 2: ___________________________________________________
City: _________________________________________________________
State: _____________________ Zip: ___________________________
Country: _____________________________________________________
Emergency Phone: ____________________________________________
_________________________________________
(Location Email)
_________________________________________
(Location Phone)
CUSTOMER’S HEALTH WARRANTY: Customer represents that he/she is in good health and has no disability, impairment, injury, disease
or ailment preventing him/her from engaging in active or passive exercise or which would cause increased risk or injury or adverse health
consequences as a result of participation in/use of Jazzercises classes and facilities. Customer assumes full responsibility for his/her use
of Jazzercises facilities, classes, programs and products and shall defend, indemnify, and hold harmless Jazzercise against any and all
claims, demands, action, losses, damages, expenses, or costs (including any applicable attorney’s fees and costs) arising out of, connected
to, or related to Customer’s use of the facilities, classes, programs and/or products. Physical examinations by Customers physician are
recommended and encouraged for Customers before starting an exercise program, and especially Customers unaccustomed to physical
exertion, or who have physical limitations, a history of high blood pressure, heart problems or other chronic illnesses, or Customers who
have a history of heart disease. Customer represents to Jazzercise that the Customer either has the permission and approval of his/her
physician to participate in the athletic activities, programs, and exercise classes and use of exercise equipment or if he/she does not have
such permission, the Customer hereby assumes the risk of injury and death, which may result from such activities.
REASONABLE CONTACT: By signing this Agreement Customer gives consent to receive reasonable Jazzercise communications via
text message, electronic mail, direct mail and telephone calls in addition to Jazzercise marketing sent via electronic mail, text message,
push notication, direct mail, or telephone. Customer may change his/her communication preferences at any time by speaking to
Jazzercise location.
WAIVER OF LIABILITY: Customer agrees and understands that there are risks associated with the use of Jazzercises facilities, programs
and activities. Customer further agrees and understands that Customer is assuming the risks associated with the use of the facilities, classes,
programs, activities and all equipment contained therein including the risk of injury and death. For and in consideration of the use of the
facilities, activities, and programs, Customer agrees to release, discharge, and waive any claim against Jazzercise and its owners, franchisees,
agents, employees, representatives, successors, and manufacturers of equipment from any and all damages, injuries or death, arising out of,
connected to, related to, or resulting from the Customer’s use of the facilities and participation in classes, including but not limited to, the
exercise and associated equipment and athletic facilities, participation in tness programs and exercise classes.
Signature: __________________________________________________________ Date: __________________________________________
Payment Info: Class Fees Today: $_____________________ Tax: $____________________ Total Due: $_____________________
SELECT ONE TICKET TYPE:
Monthly Auto Pay: Amount: $______________ # Months Min: ______________ Other: $______________ Auto Pay Start Date: ______________
By The Class: Amount: $______________ # Of Classes (1, 10, 20, etc.): _______________________________ Other: $_____________________________
SELECT ONE PAYMENT TYPE: Credit Card/Check
Credit Card:
Cre d i t Ca rd Exp i ra t io n Dat e : __________ /___________
ACH: Check Routing #: _____________________________________________ Check Account #: _____________________________________________
I hereby authorize Jazzercise or its designee to initiate debit entries using the above-provided account information for the Total Due Now and/or the above monthly payments and for applicable
taxes, for the full term of the Agreement through the use of auto payments. If a class bundle or limited time oer (not monthly auto pay) is selected, there will be no further charge.
UPON AGREEMENT EXPIRATION, THE AGREEMENT WILL AUTOMATICALLY CONVERT TO A MONTH-TO-MONTH TERM. IT IS MY RESPONSIBILITY TO REQUEST CANCELLATION. PLEASE CONTACT
JAZZERCISE LOCATION FOR CANCELLATION POLICY OR FEES.
Payment Authorization Signature: __________________________________________________________ Date: _____________________
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