Schedule Appointment with Potential Plus

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Notes to Business (your address or any special notes about your order)

Item	Quantity	Total
Summer Sports Performance Classes (Early Bird Pricing) (60 minutes, $250.00)		$250.00
Total: $250.00

Assumption of Risk and Release of Liability:

The undersigned either as a participant or parent/guardian do hereby acknowledge my understanding there are potential risks of physical injury, harm or death with exercise and I willfully assume those risks. I acknowledge my obligation to immediately inform Potential Plus or Revved Up Fitness of any pain, discomfort, fatigue or other symptoms that I may suffer before, during, and immediately after all sessions. I understand that I may stop or delay any further training if I so desire and that the training may be terminated by the trainer upon observation of any symptoms of distress. I also understand that I may ask any question or request further explanation or information about the exercises at any time before, during and after all sessions. I hereby expressly assume the risk and waive and release any and all claims against Teays Physical Therapy Center, Inc., Potential Plus, Revved Up Fitness or any of its officers, agents, or employees, with regard to activity and participation in any of its programs and any resulting injury, disability, death, or other damage, claim or loss arising in connection with this participation, whether arising out of negligence or otherwise.

Use of Likeness by Teays Physical Therapy Center Inc., Potential Plus and Revved Up Fitness:

In agreeing to the terms of this release, I am agreeing to allow the use of my photograph and likeness for their website, social media pages, advertising, and research purposes.

If participant is under the age of 18:

I am agreeing on behalf of a minor child. I have read the above terms and conditions and give my full permission for the staff of Teays Physical Therapy Center, Inc., Potential Plus or Revved Up Fitness to administer any first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical care and transportation of the child to an appropriate medical facility.