Empowered Mama Health and Fitness Screening Form

Basic Information
Do you now or ever had in the last 12 months: (Please answer every question)
Pregnant Mamas:
Post-Partum Mamas:
Health details or anything else your instructor needs to know:
Photo Release Form for The Empowered Mama

I hereby grant The Empowered Mama the right to photograph myself and my dependent and use the photo and or other digital reproduction of myself and my dependant for publication and advertising processes, whether print, digital or electronic publishing via the Internet.

Liability Release Form for The Empowered Mama

I , ACCEPT ALL responsibility for my own person and my dependant, should an injury occur in any The Empowered Mama class. I assume all financial responsibility for any medical treatment necessary as a result of an injury during class. The undersigned, by signing this waiver of claim and release of liability, acknowledges that there are certain inherent risks associated with an exercise class, any of which could result in property damage or bodily injury. In consideration for the consent and right given to the undersigned to participate in exercise classes with The Empowered Mama., and with full understanding of the inherent risks involved, the undersigned does, by signing below, expressly assume all risks of any nature whatsoever and hereby releases and forever discharges The Empowered Mama and its employees and sub-contractors from any claim or liability of property or bodily injury of any nature whatsoever arising out of The Empowered Mama’s operation, and the undersigned acknowledges full and total personal insurance responsibility while participating with The Empowered Mama.

Important Information