Age Strong Wellness

Participant Waiver & Emergency Contact Form

Everyone joining our classes and events needs to fill this out first — it only takes about two minutes, and once it's done, you're set for everything we offer.

Your details

First name

Last name

Phone number

WhatsApp phone number (if different from above)

Email (write N/A if you have no email)

Date of birth

Home address

Emergency contact

Contact full name

Relationship to you

Contact phone

Another emergency phone number

Medical informationAny health conditions, injuries, allergies, or medications we should know about in an emergency (e.g. high blood pressure, recent knee surgery, penicillin allergy, blood thinners) — write N/A if none.

Waiver & Release of Liability

I understand that participation in activities organized by Age Strong Wellness Society — including but not limited to fitness classes, recreational activities, and events — carries a risk of injury, and in extremely rare cases, death.

By participating, I acknowledge and agree that:

I am voluntarily participating in these activities at my own risk.
I confirm that I am physically able to participate in the activities and will consult a healthcare professional if I have concerns about my ability to participate safely.
I am responsible for monitoring my own physical condition and participating within my personal limits.
I understand that Age Strong volunteers are not medical professionals and are not required to hold personal training or other fitness certifications.
I understand that Age Strong classes are not intended, advertised, or represented as treatment or relief for pain, injury, or any medical condition.
I agree not to hold Age Strong, its volunteers, and/or partners responsible for any injury, accident, illness, or death that happens while I'm taking part in their activities.
I understand that Age Strong is not responsible for any lost, stolen, or damaged personal belongings during activities or events.

Code of Conduct

I agree to treat all volunteers and fellow participants with respect.
I agree to follow the rules of the program as they are communicated to me.
I understand that these rules may change at any time, that any changes will be communicated to me, and I agree to follow them as updated.

Program Participation

I understand that Age Strong may suspend or permanently remove a participant from the program at its discretion, and I agree to accept such decisions.

I confirm that I have read and understood the Waiver & Release of Liability, Code of Conduct, and Program Participation sections above, and agree to them voluntarily.

Photo & Media Consent

I give Age Strong Wellness Society permission to take, edit, and use photos and videos of me from activities for promotional materials, community outreach, and online posting.

I give my permission for photos and videos of me to be used as described above.I do not give my permission for photos and videos of me to be used. I agree to let all volunteers know at every class so they can avoid including me in photos or videos.

Headshot

Adding a photo helps our volunteers recognize you at class. You can take one now or upload an existing photo. Your headshot will not be shared with anyone outside the organization and will never be posted online.

Participant signature *

Sign here

Please make sure all fields are filled in before submitting. You will see a confirmation message here once your form is submitted — if you don't see one, your form did not go through and you'll need to submit it again.