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PARTICIPATION AGREEMENT
FOR DAYBREAK CROSSFIT
(Wayland)

Today's Date: December 15, 2018

Even if you feel that you are physically and mentally ready to participate in our intense excercise programs, Two Limes LLC d/b/a Daybreak CrossFit ("Daybreak CrossFit") strongly recommends that you consult with a physician prior to commencing any of our programs.

PHYSICAL/MEDICAL:

I understand that there are significant risks associated with strenuous physical training and high-impact high-intensity workouts such as those of Daybreak CrossFit. I understand that there are significant risks of certain changes occurring during or following strenuous physical training and high-impact high-intensity workouts such as those of Daybreak CrossFit which may include abnormalities of blood pressure or heart rate; chest, arm or leg discomfort; dizziness, lightheadedness or fainting; and in rare instances, heart attack, stroke or even death. In rare cases, excessive strenuous physical activity can also result in exertional rhabdomyolosis. I should look for signs of excessive soreness, darkened urine, and pain in the kidney areas in the days following a particularly intense workout. I understand that other risks associated with participating at Daybreak CrossFit include, but are not limited to: slips and falls; injuries resulting from misuse of equipment and improper form; falling from equipment; falling equipment; general sports related injuries to joints, tendons, cartilage and bones, fractures, concussions, musculoskeletal injuries including head, neck, back; and injuries to internal organs.

I hereby certify that I know of no medical problems that would increase my risk of illness or injury as a result of participation in fitness programs at Daybreak CrossFit. I agree to cease activity immediately if I feel faint, lightheaded, weak, or in pain. I certify that I am in good physical condition and that I am aware of no physical impairments, illness, or injuries that will prevent me from participating in any activities at Daybreak Crossfit. For the avoidance of any doubt, I agree to discontinue activity and seek medical attention immediately if I feel faint, lightheaded, weak or in pain.

I have carefully read this Agreement and fully understand its contents. By signing this document, I acknowledge that I have been informed of the strenuous nature of Daybreak CrossFit's programs and the potential for physical injury or even death associated with high-impact high-intensity workout programs.

MEDIA:

I understand that Daybreak CrossFit may from time to time photograph, video record or otherwise document workouts and activities in which I participate in or around the Daybreak CrossFit facility for use on websites and social media and other media, as well for internal and business (e.g. newsletters) use. I hereby grant Daybreak CrossFit and assign an irrevocable right, title and license to use, simulate, and impersonate my name, likeness, voice, appearance, performance and/or biographical information, in connection with the uses described above without notice, further consent, compensation or royalty.

PERSONAL PROPERTY:

I understand that Daybreak CrossFit recommends that I not bring valuable personal property to the premises. Daybreak CrossFit and its staff are not responsible for my personal property at, or stolen from, Daybreak CrossFit.

AUTOMATED BILLING AND CANCELLATIONS:

I understand that if I join Daybreak CrossFit, my monthly membership will automatically be charged to the payment method on file on the 1st of each month. I also understand I have the right to cancel my membership via email at least 2 working days before the 1st of the month, at which time automatic charges will no longer occur. I understand there are no partial month refunds.

In the event that any provision of this Agreement is deemed inconsistent with the Massachusetts General Laws Chapter 93 80 as it may be amended from time to time, such provisions shall be deemed to be null and void.

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

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
How did you learn about Daybreak CrossFit?*
Web Search
Friend or Family
Sign on Route 20
Other
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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical / Physical Information


DOES THE PARTICIPANT HAVE OR HAD ANY OF THE FOLLOWING: 

Heart Disease*
No
Yes
Heart Attack*
No
Yes
Irregular Heart Beats or Murmurs*
No
Yes
Heart Valve Problems*
No
Yes
Heart Surgery*
No
Yes
Chest Pain*
No
Yes
Cancer*
No
Yes
Angina*
No
Yes
Stroke*
No
Yes
Epilepsy*
No
Yes
Asthma*
No
Yes
Hypertension*
No
Yes
Diabetes*
No
Yes
Dizziness /Loss of Balance*
No
Yes
Bone, Joint, Tendon or Muscle Problems*
No
Yes
Back Pain, Knee Pain, Shoulder Pain*
No
Yes
HAS A DOCTOR TOLD THE PARTICIPANT THAT THEY HAVE ANY CONDITION THAT WOULD PREVENT THEM FROM UNDERTAKING STRENUOUS PHYSICAL ACTIVITY?*
No
Yes

If you answered "Yes" to any of the foregoing, please explain and do not undertake activities at our facilities without a recommendation to do so by your physician:

DOES THE PARTICIPANT CURRENTLY:

Smoke?*
No
Yes
Drink Alcohol?*
No
Yes
Currently exercise at least 2x per week for at least 20 minutes at a time?*
No
Yes
Take prescription meds which may interfere with strenuous activity?*
No
Yes

If "Yes", please list:
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
How did you learn about Daybreak CrossFit?*
Web Search
Friend or Family
Sign on Route 20
Other
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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