Loading...

Required for new and prospect athletes training at The Dirty Gym | Dayton OH.

Facility Safety Agreement:

Athletic training is dangerous and potentially life threatening.

Sports accidents often occur, leading to loss of limb or life. Training for competition increases the chance of injury. If you are uncomfortable, unsure, unaware, and/or unable to perform a movement (any movement), do not engage. Do not attempt anything without proper safety measures, do not attempt anything that your coach/trainer has not instructed. Do not train, exercise, or perform any related exercise movements without a coach/trainer present.

NO bench pressing without a spotter!

NO squatting without: spotters, safety straps, spotter pins/trays!

DO NOT TRAIN ALONE!

Pay attention at all times and understand what you are willingliy participating in!

Photography and Video Release:

Athletes involved in any activities offered by “The Dirty Gym” may be photographed or videotaped during training.

The undersigned hereby consent(s) to the use of these photographs and/or videos without compensation, on the “The Dirty Gym” website or in any editorial, promotional or advertising material produced and/or published by “The Dirty Gym,” and/or “Dirty Work LLC”, and/or its subsidiaries.

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 nit 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. I am aware that any of these above mentioned risks may result in serious injury and/or death to me and/or my partner(s).

I willingly assume full responsibility for the risks that I am exposing myself to and willingly accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under direction of “The Dirty Gym,” its coaches, trainers, clinic leaders, speakers, and the like.

I also acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others.

Waiver and Release of Liability:

Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by “The Dirty Gym,” I, the undersigned hereby release “The Dirty Gym,” 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 “Dirty Gym” 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.

Indemnification:

The undersigned recognizes that there is risk involved in the types of activities offered by "The Dirty Gym".

Therefore the undersigned 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, the undersigned agrees to reimburse them for such fees and costs. The undersigned further agrees to indemnify and hold harmless “The Dirty Gym,” their principals, 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 activities offered by “The Dirty Gym,” 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 “The Dirty Gym.”

The undersigned has read and understood the foregoing assumption of risk(s), and release of liability and understands that by signing it obligates them 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. The undersigned understands that by signing this form they are waiving valuable legal rights.

First Athlete's Name

First Name*

Last Name*

Phone*
First Athlete's Date of Birth*
First Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
First Athlete's Signature*
Second Athlete's Name

First Name*

Last Name*
Second Athlete's Date of Birth*
Second Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Second Athlete's Signature*
Third Athlete's Name

First Name*

Last Name*
Third Athlete's Date of Birth*
Third Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Third Athlete's Signature*
Fourth Athlete's Name

First Name*

Last Name*
Fourth Athlete's Date of Birth*
Fourth Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Fourth Athlete's Signature*
Fifth Athlete's Name

First Name*

Last Name*
Fifth Athlete's Date of Birth*
Fifth Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Fifth Athlete's Signature*
Sixth Athlete's Name

First Name*

Last Name*
Sixth Athlete's Date of Birth*
Sixth Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Sixth Athlete's Signature*
Seventh Athlete's Name

First Name*

Last Name*
Seventh Athlete's Date of Birth*
Seventh Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Seventh Athlete's Signature*
Eighth Athlete's Name

First Name*

Last Name*
Eighth Athlete's Date of Birth*
Eighth Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Eighth Athlete's Signature*
Ninth Athlete's Name

First Name*

Last Name*
Ninth Athlete's Date of Birth*
Ninth Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Ninth Athlete's Signature*
Tenth Athlete's Name

First Name*

Last Name*
Tenth Athlete's Date of Birth*
Tenth Athlete's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Tenth Athlete's Signature*
Athlete's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to Subscribe to the Gym Newsletter.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's General Health Information
Please check any of the following that apply to your Medical History:
Smoker
Consume Alchohol
Diabetes
High Blood Pressure
Heart Disease

List any current Medications:

List any recent (or relevant past) Surgeries, Injuries or outstanding Health Conditions:
Parent or Guardian's Signature*
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 checking here, you are waiving that right. After 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 email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!