Waiver Form | Zero Gravity Pole

First name

Last name

Phone

Birthday

Country/Region

Address

City

Zip / Postal code

Emergency Contact Name

Emergency Contact Number

Does the above named person suffer from any medical conditions that may effect their participation in any classes held at Zero Gravity Pole If so please give details

Are you currently on any medication (if so please provide details)

I have informed Zero Gravity Pole of any medical conditions that may affect my participation in classes and will continue to keep Zero Gravity Pole informed of any changes in health in the future.

I acknowledge that i have read the waiver and release information, and fully understand its terms, I agree that a copy of this waiver liability policy has been made available to me for my own records view the full Liability Waiver here

Signed

In order book private or group pole classes please contact us directly as bookings not available on line

Liability Waiver Form