Registration/ Waiver

FABULOUS FIT & FIERCE (F3)

Home
Calendar (General Sessions)
Start Here*
- Registration/ Waiver
- Service Booking Page
Sessions Payment Options ($)
Locations
- Main: Samuel Puccio Brazilian Jiu-Jitsu
Contact
- Message
- What Type of Classes would you like to see added?
Main Website: ANESTEA SERVICES LLC: WHOLESTIC LIFESTYLE COACHING-CONSULTING

Before Attending a Session, We Must Require You Fill out our:

Link to our Minors Registration, Consent and Waver (17 yrs of age and below)

Registration/ Waver
Adult (18 and above)

* Indicates required field

Name *

First

Last

Email *

Phone Number *

If None Type- NA

Cell/ Mobile Phone Number *

In None Type -NA

Telephone Request Callback? *

Yes No

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth: 00/00/0000 *

Please use the Following format: 00/00/0000

AGE *

Are you Under the age of 18 *

Yes No

If Yes Provide Adult Gordian/Parent Approval.

If you answered Yes to the Above you must provide a Parent/ Guardian name and have them fill out our Minors Registration, Consent, Waver Form.

By typing Parent/Guardian First and Last name here you acknowledge that You have permission to attend our programs. You also Agree that Said forementioned person agrees to be present at first class, session, event etc. *

Are you or a relative of yours a Member of One of our Programs/ Schools? *

If Other please list Name Below.

Please list other: *

Waiver Release: I hereby consent to participate in activities offered by Anestea Services LLC, and any Coaches, Consultants or Collaborators. It is hereby agreed that I and/or my children waive and release all right and claims for damages that I and/or my children may have at any time, for any injury or damages, in connection with any and all programs, services or other activities. The risks involved in respect to such a program are fully understood. *

Yes No

Permission for Medical Treatment: I confirm that the previously named person is in good health, unless indicated below. I hereby authorize simple first aid. *

Yes No

Do you have Any Medical Concers/ Disabilities that we need to know about YesNo *

Yes No Do Not Know

If Yes please list below:

Medical Concerns *

Please list Any Medical concerns, disabilities, Injuries here.

CONSENT FOR PRODUCTION AND USE OF VERBAL OR WRITTEN STATEMENTS, PHOTOGRAPHS, DIGITAL IMAGES, AND/OR VIDEO OR AUDIO RECORDINGS BY Angela L. C. Smith or Anestea Services NOTE: The execution of this form does not authorize production or use of materials except as specified below. The photograph, digital image, and/or video or audio recording will be produced while I am Participating in Activities with or related to Angela L. C. Smith and/ or Anestea Services. The specified material may be produced and used by Angela L. C. Smith and/or Anestea Services for authorized purposes such as education, research activities, or promotional efforts. It may also be disclosed as permitted by law. The purpose of this form is to document your consent to Angela L. C. Smith and/ or Anestea Services request to obtain, produce, and/or use a verbal or written statement or a photograph, digital image, and/or video or audio recording containing your likeness or voice. *

Yes No

By signing this form, you are authorizing the production or use. You may rescind your consent at any time prior to or during production of a photograph, digital image, or video or audio recording, or before or during your provision of a verbal or written statement. You may rescind your consent after production is complete if the burden with that request is not unreasonable considering the financial and administrative costs, the ease of compliance that number of parties involved.

By typing you First and Last name here you acknowledge that all the information given in correct to the best of your knowledge and you agree to the waver conditions as indicated. Electronic Signiture (First and Last name Please) *

How did you learn of our Program? *

Thank you for your time. Please leave any Comments you would like to share. *

I agree to receiving marketing and promotional materials

Submit

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Home
Calendar (General Sessions)
Start Here*
- Registration/ Waiver
- Service Booking Page
Sessions Payment Options ($)
Locations
- Main: Samuel Puccio Brazilian Jiu-Jitsu
Contact
- Message
- What Type of Classes would you like to see added?
Main Website: ANESTEA SERVICES LLC: WHOLESTIC LIFESTYLE COACHING-CONSULTING

Before Attending a Session, We Must Require You Fill out our:

Registration/ Waver Adult (18 and above)

Registration/ Waver
Adult (18 and above)