If you answer yes to any of the following questions, please explain your answer in the box provided. If no, leave blank.
I, First Name Last Name , have volunteered to participate in a program of physical exercise under the direction of Dale Dymkoski, which will include, but may not be limited to, weight and/or resistance training. In consideration of Dale Dymkoski’s agreement to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless Dale Dymkoski from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this exercise program, including any injuries resulting from them. I, First Name Last Name , recognize that exercise might be difficult and strenuous and there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise do exist. These changes include abnormal blood pressure, fainting, disorders in heartbeat, heart attack, and in rare instances: death. I recognize that an examination by a physician should be obtained prior to involvement in an exercise program. If I, First Name Last Name , have chosen not to obtain a physician’s permission prior to beginning this exercise program with Dale Dymkoski, I do so at my own risk.I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHTS I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST DALE DYMKOSKI. First Name Last Name