POLE WORX INC.

Classes Waiver Form

Informed Consent/Release of Liability ***Please read carefully***

I, __________________________________, admit knowingly and willingly that I have enrolled in a physical fitness program that includes, but is not limited to, jumping, stretching, strength training, and exercising in the location of Pole Worx 1225 Union Ave. Kansas City, Missouri. In consideration of my entry and of my own free will, I (the undersigned) do hereby for myself and my heirs, executors, and administrators, waive, release, and give up any and all claims, demands, liability, damages, costs and expenses of any kind whatsoever (including personal injury to me or my wrongful death) against Pole Worx INC., Pole Worx instructors and any persons involved in the program and all of its affiliates (including but not limited to instructors, participants, the City of Kansas City, County of Jackson, Highways and Transportation District, its officers, directors, employees, contractors and subcontractors), that may arise from my participation in Pole Worx activities or while traveling to and from the classes, even if caused in whole or in part by the negligence or other fault of the aforementioned parties or persons. I fully understand that I may injure myself as a result of my participation in this program and hereby release Pole Worx INC., and aforementioned facilities from any liability, now or in the future, including but not limited to heart attacks, muscle strains, sprains, pulls, tears, broken bones, shin splints, heat exhaustion, knee, back, or foot injuries and any other illness, soreness, or injury, however caused, occurring during or after my participation in this exercise program. It is further agreed that all exercises including the use of equipment, as well as travel to and from the Pole Worx location shall be AT MY OWN RISK. This waiver applies to every state/country. I FULLY UNDERSTAND THAT I AM FOREVER GIVING UP, IN ADVANCE, ANY RIGHT TO SUE OR MAKE CLAIMS AGAINST THE PARTIES I AM RELEASING, IF I SUFFER ANY INJURIES OR DAMAGES, EVEN THOUGH I DO NOT KNOW WHAT OR HOW EXTENSIVE THOSE INJURIES AND DAMAGES MIGHT BE AND AM VOLUNTARILY ASSUMING THE RISK OF SUCH INJURIES OR DAMAGES. I UNDERSTAND THIS CONSENT FORM AND AM NOT UNDER ANY PHYSICAL OR EMOTIONAL DURESS TO SIGN.

Signature X____________________________________________________

DATE:_______________

EMAIL:____________________________________________________