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Health Assessment And Waiver, Release Of Liability
Give us some information on your health history and let us know which class you’d like to attend.
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Name
*
First
Last
Date of Birth
*
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email Address
*
In case of emergency, I would like CrossFit Coweta to call: (Name & Phone Number)
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Health Assessment
Have you ever had any form of heart disease?
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Yes
No
Have you ever experienced shortness of breath or chest pains?
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Yes
No
Date of last full physical
*
Do you have or do any of the following pertain to your health?
If yes, please explain.
High Blood Pressure
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Yes
No
If yes, what are your levels?
Cigarette Smoking
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Yes
No
Diabetes
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Yes
No
If yes, what type(s)?
Family History of Heart Disease
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Yes
No
If yes, who and what age?
Do You Work Out At Least 3 Times Per Week?
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Yes
No
Are You Currently Taking Any Medication?
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Yes
No
If yes, please explain.
Do You Have Problems In Any Of The Following Areas?
Knees
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Yes
No
Lower Back
*
Yes
No
Neck/Shoulders
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Yes
No
Hip/Pelvis
*
Yes
No
Any Other Body Parts?
*
Yes
No
Is There Any Other Reason You Know Of That You Should Not Participate In Certain Exercise(s)?
Express Assumption of Risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. These risks include, but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, my training partner, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above mentioned risks may result in serious injury or death to me and/or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under direction, of CrossFit Coweta. I, the undersigned, acknowledge that I have no physical impairments or illnesses that will endanger myself or others.
*
Clear Signature
Date
*
Release: In consideration of the above mentioned risks and hazards and in consideration of that fact that I am willingly and voluntarily participating in the activities offered by CrossFit Coweta, I, the undersigned hereby release CrossFit Coweta, their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. 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 CrossFit Coweta 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.
*
Clear Signature
Indemnification: The participant recognizes that there is risk involved in the types of activities offered by CrossFit Coweta. Therefore the participants accepts financial responsibility for any injury that the participant may cause either to him/herself or to any other participant due to his/her negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless CrossFit Coweta, their principles, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activies offered by CrossFit Coweta, at the main building or abroad. This includes but is not limited to parks, recreational areas, playgrounds, areas adjacent to main building, and/or any area selected for training by CrossFit Coweta
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Clear Signature
Signature: I have read and understand the foregoing assumption of risk, and release of liability, and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.
*
Clear Signature
Date
Release & Indemnification Signature if the participant is under the age of 18, Signature of Parent or Guardian:
Clear Signature
Date
(Parent/Guardian) Print Name
Photography/Video Release: Participants involved in any activities offered by CrossFit Coweta may on occasion be photographed or videotaped during training. The undersigned hereby consents to the use of these photographs and/or videos without compensation on the CrossFit Coweta Website or in any editorial or promotional material produced and/or published by CrossFit Coweta.
Clear Signature
Date
*
Submit
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