Please print this form, complete and sign it, then mail the signed copy with your license fee to the address below.

Name of Facility
_______________________________		 Date
__________________________
Name and Title of Person Authorizing this Purchase
_______________________________		 Title or Position
__________________________
Address of Facility
_______________________________		 Facility Phone Number
__________________________
City State
__________________ __________
Zip Code County
__________________ __________
Secondary Phone Number
__________________________

Fax Number
__________________________
Name of Additional Facilities (If any)
_______________________________		 Federal Tax I.D. Number
__________________________
Facility Status
Recreation Center Senior Center Health Club
Retirement Community Hospital University/College
Wellness Center Other_______________________
Name of Activity Director and/or instructor(s)

__________________________

__________________________

Waiver of Liability and License Agreement

In consideration of my purchase of the Geri-Fit® exercise program offered by Geri-Fit®, Ltd., I hereby waive any and all claims for injuries, damages, lawsuits, deaths or other losses which I may have or acquire against Geri-Fit®, Ltd., its board members, owners, employees, agents or sponsors of the Geri-Fit® program. I further acknowledge that all participants to whom I offer the program will be physically able to participate and that my instructor for the Geri-Fit® program will follow all the guidelines as prescribed in the Training Video and Manual and said instructor will conduct the program in a professional manner. I understand that the cost of the program and trademark license is a one-time fee of $750 per location where the program is offered. I also understand that I am not able to act on my own or as a consultant in any capacity whatsoever in any attempt to duplicate this program for my own purpose or for another individual or company and that all manuals and videos are Federally copyrighted and may not be duplicated or reproduced in any manner or under any circumstances whatsoever. I agree that the materials given to me are to be used solely for conducting the classes at the location listed above. I agree that this license is non-transferable, I will not be entitled to any refunds for the program and I will pay a $150 annual renewal fee. I also agree to keep in full force and effect liability insurance which covers my activities related to the Geri-Fit® program and hold Geri-Fit®, Ltd. free and harmless from any claims resulting from the use of the program.

Signature: Title: Date:
_______________________ _______________________ _______________________
Method of Payment:
   Check
   VISA
   MasterCard

Credit Card Number:
________ - ________- ________ - ________

Exp. Date: ________

Signature:__________________

Date:________  Total:_________

Geri-Fit® Program License $750
   Sub-Total $750
   Shipping and handling $20
   Total $770
Fax completed form to
330-655-9347 or mail to:

GERI-FIT® LTD.
P.O. BOX 444
Hudson, OH 44236-0444


Geri-Fit® Company, Ltd.
P.O. Box 444
Hudson, OH 44236
Tel: 330-650-3539
email:gerifit@aol.com