Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participants Date of Birth *

MM

DD

YYYY

How did you hear about us? *

Friend/Family

Current Member

Google

Facebook

Instagram

Have you ever had any form of heart disease? *

Yes

No

Do you have any current injuries? *

Yes

No

Have you ever experienced shortness of breath or chest pains? *

Yes

No

Do you have any allergies? *

Yes

No

Do you have a family history of heart disease *

Yes

No

Do you have high blood pressure? *

Yes

No

Do you ever get dizzy? *

Yes

No

Are you a smoker?

Yes

No

Are you currently taking any medication? *

Yes

No

Do you have problems with your knees? *

Yes

No

Do you have problems with your back? *

Yes

No

Do you have any hip/pelvis problems? *

Yes

No

Do you have any neck/shoulder problems? *

Yes

No

Are you currently exercising? *

Yes

No

Have you participated in strenuous exercise before? *

Yes

No

Are there any exercises that you know you cannot do? *

Yes

No

Is there any reason you know of that you should not participate in exercise? *

Yes

No

I understand that the training may involve lifting of small weights, gymnastic movements, bodyweight exercises and other high exertion activities, and that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand there are inherent risks in all aspects of physical training, and I acknowledge that I have been informed of the possible strenuous nature of the training and the potential for undesirable physiological results including, but not limited to, abnormal blood pressure, muscle soreness, fainting, heart attack and/or death. I warrant that I do not suffer from any medical condition that may affect my ability to participate safely in strenuous exercise. *

I agree

I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform the gym. I give the gym and the staff of the facilities I train in permission to seek emergency medical services for me should I become injured or ill with the understanding that I am responsible for any expenses incurred. If I am signing on behalf of a minor child, I also give full permission for any person connected with the facility to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well-being of the child. *

I agree

I agree to WAIVE ANY AND ALL CLAIMS that I have or may have in the future against the gym, and its directors, officers, employees, agents, volunteers, and independent contractors (all of whom are hereinafter collectively referred to as “the Releasees”). *

I agree

I agree to RELEASE THE RELEASEES from any and all liability for any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer as a result of my participation in the programs, activities and services provided by the gym, due to any cause whatsoever including negligence, breach of contract, or breach of any statutory or other duty of care. *

I agree

I agree to HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any damage to the property of, or personal injury to, any third party, resulting from my participation in any program, activity or service provided by the releasees. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect. *

I agree

Use of picture(s)/film/likeness: I agree to allow the gym, its agents, officers, principals, employees and volunteers to use picture(s), film and/or likeness of me. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform the gym of this in writing. *

I agree

I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS “INFORMED CONSENT FORM” I AM WAIVING CERTAIN LEGAL RIGHTS (INCLUDING THE RIGHT TO SUE) WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTOR, ADMINISTERS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES. ANY QUESTIONS I HAD WERE ANSWERED TO MY FULL SATISFACTION. *

I agree

Name *

By clicking "I agree" above and writing your name in the box below you acknowledge that this is the equivalent of physically signing this document.

First Name

Last Name

Todays Date *

MM

DD

YYYY