Liability Waiver: I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in a physical activity. Having such knowledge, I hereby acknowledge this release, Jason D Fitness and all business associates, affiliates, any representatives, coaches, agents, and successors from liability for accidental injury or illness which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program. I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in said fitness program. *

I understand and agree to the liability waiver

Health Insurance Provider *

TakeCare

Health Insurance Member *

Member

Dependent

Employer *

Federal (must have supplemental wellness benefit) - FedSup21

FHP

Citadel (IP&E / IT&E)

Woohyun Corp (Sushi Rock / Crab Daddy)

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Camp Location *

Which location/s would you like to attend?

Tamuning

Dededo AM

Dededo PM

Adelup

Agat

Mangilao