Name *
Name
Address *
Address
Phone *
Phone
If you would like to opt out more than one person you must complete this form for each individiual.
Date of Birth of Individual to Opt Out *
Date of Birth of Individual to Opt Out
Client being opted out is . . . *
Agreement *
By clicking the below box, I choose to opt out of the Photo-Video Release. I understand that by doing so, I may be prohibited from participating in certain programs, group classes or at certain facilities.