Other Relevant Forms
Click on the following forms, print them out, fill them out, and bring them with you.

Participant Screening Form

Childs First Name*
Childs Last Name*
Date of Birth*
Height*
Weight*
School Name*
School Address*
School Phone*

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Doctor’s Name and/or Clinic*
Office Phone*

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Medical Conditions
 Asthma  
 Diabetes  
 Hypertension  
Other
Other
Other
Parent/Guardian First Name*
Parent/Guardian Last Name*
Parent/Guardian Address*

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email*
Email Address Owner*
Home Phone Number*

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Parent/Guardian cell phone number*

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Other Contact Number

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Are there siblings that might attend with the
child?
If YES, how many:
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Are there current restrictions for child or parent
regarding exercise?
*
 Yes 
 No 
If yes, please explain
Referred by*
STRONG ME OBESITY WEIGHT MANAGEMENT PROGRAM WAIVER/RELEASE FORM For and in consideration of Memphis Pediatrics, LLC., Strong Me Weight Management Program, Zumba Fitness, LLC., Janice Pride Boone, MD, (collectively “Strong Me”) permitting the Participant to enroll in and participate in the Strong Me Weight Management Program, Participant, by signing below, hereby voluntarily indemnifies, releases from liability and hold harmless Strong Me, the Trainer, the Physician, and/or the facility for any accident, injury, illness, death, loss, damage to person or property, or other consequences suffered by Participant or any other person arising or resulting directly or indirectly from Participant’s participation in the Program. In the event Participant is injured, Participant agrees to assume any financial obligation, either through Participant’s personal health insurance, or through some other means, for any medical costs which Participant incurs. Strong Me, however, assumes no responsibility for any medical expenses, injury, damage suffered by Participant in connection with the use of any facilities, techniques or services provided by the Program.

PARTICIPANT, BY SIGNING BELOW, HEREBY EXPRESSLY ASSUMES  ALL RISK OF PERSONAL INJURY, DEATH, LOSS OR PROPERTY DAMAGE UPON HIM/HERSELF, TO THE EXCLUSION OF STRONG ME AND TO EXEMPT AND RELIEVE STRONG ME FROM LIABILITY FOR PERSONAL INJURY, LOSS, PROPERTY DAMAGE OR WRONGFUL DEATH.

Participant further agrees that Participant, his/her spouse, assignees, heirs, guardians and legal representatives will not make any claim against, sue or attach Strong Me for any loss or damage resulting from Participant’s participation in the Strong Me Weight Management Program.

PARTICIPANT IS AWARE THIS IS A RELEASE OF LIABILITY AND WAIVER OF THE PARTICIPANT’S LEGAL RIGHT TO MAINTAIN ANY ACTION OR CLAIM TO COLLECT DAMAGES IN THE EVENT OF INJURY, LOSS, DEATH OR PROPERTY DAMAGE AND A CONTRACT BETWEEN PARTICIPANT AND STRONG ME AND PARTICIPANT SIGNS THIS RELEASE/WAIVER OF HIS/HER OWN FREE WILL.

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