Waiver and Assumption of Risk
Please consult with your physician before beginning any exercise program.
I acknowledge that I have voluntarily chosen to participate in one or more physical exercise or fitness activity or sport programs
(the “Programs”). I acknowledge (i) the nature of the risks of the particular Programs in which I have chosen to participate,
and (ii) the strenuous nature of those Programs. I understand, for example, the risks associated with physical injury, abnormal
blood pressure, heart attack and even death; as well as the risks associated with the negligence of a Tivity Health Services, LLC
participating location and any other organization or individual participating or involved in providing or promoting any classes,
functions, Programs, testing, or other activities that I participate in as a Tivity Health
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Program member (including without
limitation the owners, officers, directors, employees, and representatives of any of the foregoing).
By signing this document, I expressly assume all risk for my health and well-being and expressly assume the other risks
associated with participating in the Programs, including, but not limited to, the negligence of a Tivity Health participating
location and any other organization or individual participating or involved in providing or promoting any classes, functions,
Programs, testing, or other activities that I participate in as a Tivity Health Program member (including without limitation
the owners, officers, directors, employees, and representatives of the foregoing). I also hereby release, waive, discharge and
covenant not to sue any class instructor, any Tivity Health participating location, any sponsoring organization, Tivity Health,
Inc., or any of their subsidiaries or any other organization or individual providing or promoting classes, functions, Programs,
testing, or other activities that I participated in as a Tivity Health Program member (including without limitation the owners,
officers, directors, employees, and representatives of any of the foregoing) at any time hereafter, from any and all demands,
liabilities, losses, or damages (including death, bodily injury or damage to property) caused or alleged to be caused in whole or
in part by the negligence of any of the foregoing people or entities. In addition, I agree that Tivity Health may engage in – and
I hereby expressly consent to – (i) the recording (in video and/or still photo format) of my participation in Tivity Health classes,
workshops or other programs, and (ii) the publication or other use by Tivity Health of any such recordings in social media,
broadcast media, print media, general advertising and similar purposes.
I have read and understand this waiver and express assumption of risk. I have also read, understand, and will adhere to all
guidelines and policies in regard to this benefit. This waiver and release shall survive the term of any agreement with a Tivity
Health participating location or individual.
In the event that my physician has recommended any limitations to my physical activity or I have experienced any of the
following conditions, I hereby attest that I have informed my physician of the condition(s) and have obtained express consent
from my physician to participate in the Programs.
• Chest pains while at rest and/or during exertion, previous heart attack or high blood pressure
• Any heart or circulatory conditions, such as vascular disease, stroke, chest pain, congestive heart failure, poor circulation
to the legs, valvular heart disease, blood clots
• Frequent fast, irregular heartbeats OR very slow heartbeats
• Diabetes
• Previous hip or spinal fracture (as an adult)
• Lung disease or shortness of breath after mild exertion, at rest, or in bed
• Open cuts on my feet that do not seem to heal
• An unexplained weight loss of ten (10) pounds or more in the past six (6) months
• More than two falls in the past year (no matter what the reason)
• More than one year since I have engaged in regular physical activity
Print Member’s Name Member’s Signature Date of Birth
Emergency Contact Name
Emergency Contact Pho
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e Number Date
SSFP2981WAIVER0617
Street Address
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Member Phone Number
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