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In order to ensure your safety, please take a moment to fill out this consent form. Please note that if we have not received your form by the start of class, you will not be allowed to participate. 

Participant Information

Emergency Contact

I understand that I am participating in Pilates classes, Health Programs and/or Workshops offered by Melody Jordan and Schmizza Public House Lebanon during which I will receive information and instruction about movement and health. I understand that the practice of Pilates involves physical exertion that may be strenuous and may cause injury, and I am fully aware of the hazards involved. I also understand that it is my responsibility to consult with a physician prior to and regarding my participation in Pilates, Health Programs and/or Workshops. I represent and warrant that I am physically fit and have no medical condition that would prevent my full participation. I agree to assume the full responsibility for any risks, injuries or damages, known or unknown, that I may incur as a result of participating in these classes or workshops. I knowingly, voluntarily and expressly waive any claim I may have against Melody Jordan and Schmizza Public House Lebanon for injury or damages that I may sustain as a result of participating in the classes or sessions. I, my heirs and legal representatives forever release, waive, discharge and covenant not to sue Melody Jordan and Schmizza Public House Lebanon for any injury or death caused by her negligence or other acts. I acknowledge that it is my responsibility to inform the instructor when I begin a class of any injury or other condition that might affect my ability to participate, and to inform the instructor at each class I attend. 

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