Loading...

Health Assessment Waiver Form

TODAY'S DATE: January 22, 2025

INFORMED CONSENT/ASSUMPTION OF RISK

I, agree to participate in one or more physical fitness program(s)/class(es) sponsored by DRS Athletics, which may include, but not necessarily be limited to, Cross Fit Training, and/or training of any kind by any affiliate, subsidiary or partnership of DRS Athletics. I am fully aware that the fitness programs/classes which DRS Athletics offers and in which I desire to participate are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. I the undersigned recognize and understand that the programs/classes are not without varying degrees of risk which may include, but are not limited to the following:

Injury to the musculoskeletal and/or cardio respiratory systems 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, or injury or death due to a medical condition, whether known or unknown by me. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s). 


I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in DRS Athletics programs/classes and accept full responsibility for any injury or death that may result from participation in any activity, class or physical fitness program. I herby certify that I know of no medical problems that would increase my risk of illness and injury as a result of participation in a fitness program designed by DRS Athletics. I understand that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. I also understand that these changes could include abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and in very rare instances, heart attack or even death, and I fully understand the same. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in DRS Athletics fitness programs/classes.


I also understand that there is no child care available and that I am responsible for others including children and adults that I may bring with me. They will not be allowed in the workout area and/or will not use any of the equipment. There is a designated area for non participants. This waiver in its entirety will also cover others in my care and/or others that accompany me.


Release: 

In full consideration of the above mentioned risks and hazards and in full consideration of the fact that I am willingly and voluntarily participating in the activities made available by DRS Athletics, and with my full understanding of all of the above, I hereby waive, release, remise and discharge DRS Athletics and its agents, officers, principals and employees and volunteers, of any and all liability, claims, demands, actions or rights of action, or damages of any kind related to, arising from, or in any way connected with, my participation in DRS Athletics fitness programs/classes, 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 DRS Athletics 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. [initial

Indemnification: I recognize that there is risk involved in the types of activities offered by DRS Athletics. Therefore I accept financial responsibility for any injury that I or 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 attorneys 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 DRS Athletics, 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 DRS Athletics.


Use of picture(s)/film/likeness: I agree to allow DRS Athletics, its agents, officers, principals, employees and volunteers the a 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 DRS Athletics of this in writing.


I have fully read and fully 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. Email will be used for correspondence and newsletters. 

DISCLAIMER OF MEDICAL ADVICE: By participating in the Services provided by the Company, I acknowledge and understand that the services, content, and programs offered are not a substitute for professional medical advice, diagnosis, or treatment. I am aware that the Release Parties are not healthcare providers and have no expertise in diagnosing, examining, or treating medical conditions of any kind. I understand that it is my responsibility to consult with a qualified healthcare provider for diagnosis and treatment, including participation in any exercise or program offered by the Company. I acknowledge that participating in these activities without the approval of my healthcare provider is done at my own risk.


CONFIDENTIALITY AND SHARING OF MEDICAL AND SENSITIVE INFORMATION: I understand that any medical or sensitive information I provide to the Company will be used solely for the purpose of enhancing my experience and safety during the Services. I acknowledge that this information may be shared among the Company staff members as necessary. The Company is committed to maintaining the confidentiality of my personal information and will take reasonable precautions to protect it from unauthorized access or disclosure. However, I understand that no method of electronic storage or transmission is the Company cannot guarantee absolute security of my information. 


TODAY'S DATE: January 22, 2025

Please select who will be participating...
AdultMinor
Continue
First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Occupation:
First Participant's Signature*
Participant'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

First Name*

Last Name*

Emergency Contact's Phone Number*
HEALTH ASSESSMENT
Have you ever had any form of heart disease?*
Have you ever experienced shortness of breath or chest pains?*

Date of last full physical:

Do you have or do any of the following pertain to your health?

High Blood Pressure

If Yes, Levels:
Cigarette Smoking
Diabetes

If Yes, Types:
Family History of Heart Disease

Who/Age:
Do you work out at least three times per week
Are you currently taking any medication

If Yes, please describe:

Do you have problems in the following areas:

Knees
Lower Back
Neck/Shoulders
Hip/Pelvis
Any Other

If you checked any of the above, please describe:

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

Parent and/or Guardian must sign below for minors: AGREEMENT AND RELEASE OF LIABILITY In consideration of having DRS Athletics, LLC allow my child, who is under the age of 18 to participate in the activities and programs of DRS Athletics LLC., including but not limited to DRS Athletics LLC, Climbing and use of the climbing wall and any other equipment, I hereby for my child’s heirs, executors, administrators, and or assigns, waive and release any and all rights and claims of any nature my child may have against DRS Athletics LLC, its officers, employees, agents, chapters, assignees, licensees, and cooperating entities, their representatives, heirs, executors, administrators, successors, and assigns for and against any and all injuries or damages of any nature my child may suffer while taking part in any activities connected with DRS Athletics LLC. This release and consent shall be binding upon my child’s heirs, executors, administrators, and/or assigns.



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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Occupation:
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!