Liability Waiver | The Breakaway Prog.

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The Breakaway Program

Medical, Liability, and Media Agreement

Please fill out the following medical form, and communicate in person before starting classes of any physical issues we need to be aware of.

First Name

Email Address

Last Name

Date of Birth

Are there any medical conditions or injuries that we need to be aware of? Please List:

Is this athlete taking any medication/s? Please List:

Today's Date

Medical, Liability, and Media AgreementPlease Read and Check Box

Thanks for submitting!

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