CrossFit Vivid Waiver - CrossFit Vivid

Participant's Name*

First Name Last Name

Phone Number *

Participant's Date of Birth*

Participant's Information*

Occupation

Participant's Address*

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Emergency Contact

Emergency Contact Name

Emergency Contact Number

Client Questionnaire*

Have you knowingly suffered from any of the conditions above?

If you have TICKED the YES box to the above question, or have any other condition please give details:*

Do you regularly smoke?*

No
Yes

Are you taking any non prescribed or medications?*

No
Yes

Do you experience any side effects from these medications?*

If yes, Please provide Details*

Have you participated in strength and conditioning before joining CrossFit Vivid?*

What is your preferred method of contact:*

Have you ever had any form of heart disease?*

Yes
No

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

Yes
No

Do you have problems with your knees?*

Yes
No

Do you have any hip/pelvis problems?*

Yes
No

Do you have any neck/shoulder problems?*

Yes
No

Do you have diabetes?*

Yes
No

Are you currently taking any medication?*

Yes
No

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

Yes
No

How did you hear about us?*

Electronic SIgnature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current address in order to contact you regarding any changes, if necessary.

In consideration of Hills Health and Fitness Pty Ltd allowing me to participate, I acknowledge, understand and am aware that: I have voluntarily chosen to participate in training activities provided by Hills Health and Fitness Pty Ltd trading as “New Beginning Performance”. 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 understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my trainer. I give Hills Health and Fitness and the staff of the facility 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. I agree to WAIVE ANY AND ALL CLAIMS that I have or may have in the future against Hills Health and Fitness Pty Ltd, and it’s directors, officers, employees, agents, volunteers and independent contractors (all of whom are hereinafter collectively referred to as “the releases”) 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 Hills Health and Fitness Pty Ltd, due to any cause whatsoever including negligence, breach of contract, or breach of any statutory or other duty of care. 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. If I am signing on behalf of a minor child, I also give full permission for any person connected with Hills Health and Fitness Pty Ltd 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 wellbeing of the child. Use of pictures(s)/film/likeness: I agree to allow Hills Health and Fitness Pty Ltd, its agents, officers, principals, employees and volunteers to use picture(s), film and/or likeness of me for advertising purposes. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform Hills Health and Fitness Pty Ltd of this in writing. I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS “INFORMED CONSENT FORM” I AM WAVING 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.

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