Participant Medical Disclosure and Injury Release Form

Bodyshift Fitness Membership Wizard

Step 1 of 6

Personal Information

Full Name

Date of Birth

Phone

Address

Emergency Contact

Emergency Phone

Select Membership

Annual Paid in Full — $500

Annual Monthly — $50

Month to Month — $65

Couples Paid in Full — $900

Apply Military / First Responder Discount

Payment Authorization

Card Type

Last 4 Digits

Expiration

Billing Zip

Medical Disclosure

Conditions, Injuries or Allergies

Agreement + Signature

I agree to Membership Terms I accept Liability Waiver I authorize recurring billing

Sign Below

Review & Submit

Please review your information, then click Submit to complete enrollment. Upon submission: • A copy is emailed to you • A copy is emailed to Bodyshift • You’ll be redirected to bodyshiftfitness.com