Willows Squash and Fitness Centre

Client 1

Client Details

Client First Name

Client Last Name

Date of Birth

Gender

Email Address

Confirm Email Address

Home Phone

Mobile/Cell

Caregiver/Emergency Contact Details

Caregiver's Name

Caregiver's Email Address

Caregiver's Mobile/Cell

Emergency Contact's Name

Emergency Contact's Email Address

Emergency Contact's Mobile/Cell

Address

Address 1

Address 2

Suburb/Town

State/Prov

Zip/Postcode

Health and Fitness

Do you have any injury concerns?

Do you have any medical conditions?

DISCLAIMER:
Release and Indemnity In consideration of the acceptance of my payment for participating in the activity (and except to the extent that the same may be precluded by state) I agree to release and indemnify Willows Health and Lifestyle Centre as follows: • I participate in the activity at my sole risk and responsibility • I release, indemnify and hold harmless Willows Health and Lifestyle Centre, its servants and agents, from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of or arising out of any injury, loss, damage, or death caused to me or my property whether by negligence, breach of contract or in any way whatsoever. I also agree that in the event that I am injured or my property is damaged, I will bring no claim, legal or otherwise, against Willows Health and Lifestyle Centre in respect of that injury or damage. Where Participant is under 18 years of age: I being the parent/guardian of the person named in the acknowledgement and release hereby acknowledge and agree that: • I have read the whole of this document and understand it. • I consent to the person named in this acknowledgement and release participating in the activity and • I am aware of the risks, dangers and obligations set out above in the acknowledgement and release. In Consideration of the person named in the Acknowledgement and Release being accepted to participate in the activity. I agree to release and indemnify Willows Health & Lifestyle Centre in the same manner and to the same effect and extent as if I were the person first named in this Acknowledgement and Release and the person participating in the activity.

Agreement

Please mail this form with a payment attached to: "Willows Health & Lifestyle Centre, 55-57 Kitchener Street , Toowoomba QLD 4350"