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Waiver for Reynolds Goto Group Pty. Ltd. trading as CrossFit U.

I have voluntarily chosen to participate in training activities provided by a Reynolds Goto Group Pty. Ltd, trading as CrossFit U. 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 the training may involve weightlifting, gymnastic movements, strenuous 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 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 Reynolds Goto Group Pty. Ltd Ltd 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.

I agree to WAIVE ANY AND ALL CLAIMS that I have or may have in the future against Reynolds Goto Group Pty. Ltd, and its directors, officers, employees, agents, volunteers and independent contractors (all of whom are hereinafter collectively referred to as the Releasees). 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 Reynolds Goto Group 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 Reynolds Goto Group Pty. Ltd 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 well being of the child.

Use of picture(s)/film/likeness: I agree to allow Reynolds Goto Group 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 Reynolds Goto Group 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 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.

November 17, 2019

 

First Athlete's Name

First Name*

Middle Name

Last Name*

Phone*
First Athlete's Date of Birth*
First Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
First Athlete's Signature*
Second Athlete's Name

First Name*

Middle Name

Last Name*
Second Athlete's Date of Birth*
Second Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
Third Athlete's Name

First Name*

Middle Name

Last Name*
Third Athlete's Date of Birth*
Third Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
Fourth Athlete's Name

First Name*

Middle Name

Last Name*
Fourth Athlete's Date of Birth*
Fourth Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
Fifth Athlete's Name

First Name*

Middle Name

Last Name*
Fifth Athlete's Date of Birth*
Fifth Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
Sixth Athlete's Name

First Name*

Middle Name

Last Name*
Sixth Athlete's Date of Birth*
Sixth Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
Seventh Athlete's Name

First Name*

Middle Name

Last Name*
Seventh Athlete's Date of Birth*
Seventh Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
Eighth Athlete's Name

First Name*

Middle Name

Last Name*
Eighth Athlete's Date of Birth*
Eighth Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
Ninth Athlete's Name

First Name*

Middle Name

Last Name*
Ninth Athlete's Date of Birth*
Ninth Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
Tenth Athlete's Name

First Name*

Middle Name

Last Name*
Tenth Athlete's Date of Birth*
Tenth Athlete's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
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 receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's 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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you ever had any form of heart disease?*
No
Yes
Have you ever experienced shortness of breath or chest pains?*
No
Yes
Do you have knee problems?*
No
Yes
Do you have back problems?*
No
Yes
Do you have any hip/pelvis problems?*
No
Yes
Do you have high blood pressure?*
No
Yes
Do you have neck/shoulder problems?*
No
Yes
Do you have current injuries?*
No
Yes
Do you have any allergies?*
No
Yes
Are you a smoker?*
No
Yes
Are you currently exercising?*
No
Yes
Have you participated in strenuous exercise before?*
No
Yes
Do you get dizzy?*
No
Yes
Is there any reason that you should not be participating in exercise?*
No
Yes

If you answer yes to any of these questions please provide more information below:
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.


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