Biggest Loser Weight Loss Challenge

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

E-mail

example@example.com

Gender*

FemaleMaleOther

Age Category*

18 yrs - 50 yrs51 yrs and older

Amount of exercise you do on a daily basis*

Less than 30 minutes30 to 60 minutesMore than 60 minutes

Are you pregnant or breastfeeding?*

YesNo

How did you hear about the challenge*

I have read and agree to abide by the Bingo Wellness challenge rules.*

Yes

Release

In consideration of my participation in the Bingo Wellness Challenge, and other good valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I for myself, my heirs, successors, executors, administrators, distributes, and assigns do hereby forever release remise waive, surrender and discharge the Putnam County Health Department, its affiliates and parents any and all volunteers, committees members, directors, officers, principals, shareholders, owners officials, representatives, members, trustees, agents, employees, successors, and assign the Putnam County Health Department from any and all personal injury, death, illness or property loss or damage and/or any and all responsibility, liabilities, actions, causes of action, claims right, judgement, demands, and executions of whichever nature or kind, foreseen or unforeseen, knows or unknown direct or indirect, nor or hereafter arising, or otherwise, in any way connected with, arising out of, resulting from or relating to my participation in the program. I acknowledge and confirm that I freely, clearly, voluntarily, and expressly agree to accept and assume full responsibility, risk and liability for any and all personal injury, death, illness, or loss of or damage to property in any way connected with or resulting arising from my participation in the program is totally voluntary.

*I acknowledge by my signature below that I have been offered a copy of the Putnam County Health Department “Notice of Privacy Practice Act (HIPAA)”, and have read the statement below.

Signature*