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Waiver and release of liability for SF GYM, WestCoast CrossFit

www.sfgym.com.au

Release of Liability, Waiver of Claims, Assumption of Risk, Indemnity Agreement, and Jurisdiction Agreement

BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE.

TO: SF Gym, owners, volunteers, directors, officers, employees, trainers, instructors, agents, officials, independent contractors, servants, representatives, successors and assigns (hereinafter referred to as SF Gym)

DEFINITIONS:

In this agreement:

  1. The term ATHLETIC ACTIVITY OR ATHLETIC ACTIVITIES includes but is not limited to personal training, fitness classes, team or individual competitions, fitness assessments, use of facilities, observation of athletic activities, Olympic lifting, power lifting, strongman training or competitions, gymnastics, strength conditioning, metabolic conditioning, plyometrics, interval training, bodyweight conditioning, bouldering, rope climbing, macro climbing, stretching, outdoor running on trails or sidewalks, sports, and programs, clinics, seminars, and services provided to the athlete by SF Gym.
  2. The term INJURY shall refer to all forms of physical, mental, and emotional injury in any way related to athletic activity and transportation activities including, but not limited to: death, breaks, strains, lacerations, dislocations, exercise induced rhabdomyolysis, heart failure, concussion, frostbite, hypothermia, heat illness, dehydration, trauma, anxiety, and fears.

DISCLAIMER:

SF Gym and their owners, volunteers, directors, officers, employees, trainers, instructors, agents, officials, independent contractors, servants, representatives, successors and assigns (hereafter referred to as SF Gym) are not responsible for any death, injury, loss, or damage of any kind suffered by any person while using SF Gym facilities, participating in or watching SF Gym activities, caused in any manner whatsoever including, but not limited to, the negligence of SF Gym. I am aware that athletic activities have inherent dangers and risks including but not limited to the potential for serious personal injury or death caused by any SF Gym athletic activities or any condition of the facilities or equipment of SF Gym, some of which include:

  1. Transient light-headedness, fainting, abnormal blood pressure, chest discomfort, muscle cramps, muscle soreness, pain, discomfort, fatigue, nausea, heart failure, exercise induced rhabdomyolysis, and so forth;
  2. All manner of injury resulting from slipping or falling, either roped or unroped, while jumping, skipping, running, walking, lifting, climbing, and impacting against the floor, walls, equipment, other athletes, or any permanent or temporary fixtures or equipment;
  3. Abrasion, entanglement, lacerations, bruising, dislocation, and other injuries resulting from activities on or near stands, racks, weight bars, pull-up bars, walls, ropes, cargo nets, medicine balls, and plyo boxes;
  4. Injuries resulting from falling athletes or objects such as weights, dumbbells, bars, medicine balls, ropes, and so forth or by any objects dropped by other persons conducting athletic activities or assisting others;

Failure of the equipment, racks, stands, bars, attachments, anchors, ropes, harnesses;And, I do hereby further acknowledge and agree:

  1. That the athletic activities I am participating in requires a moderate to high degree of effort, are designed to be high intensity, and are intended to maximally challenge my cardiovascular endurance, stamina, strength, flexibility, speed, power, coordination, agility, balance, and accuracy;
  2. That I will honestly represent my level of fitness, health, nutrition, use of medication, medical history, and current physical, mental, and medical condition to SF Gym;
  3. That although SF Gym takes steps to reduce the risks and increase the safety of all athletic activities, it is not possible for SF Gym to make these athletic activities completely safe;
  4. That I am personally responsible for my preparation prior to athletic activities, my concentration and attention during these athletic activities, and for my post activity rest and recovery;
  5. That I will learn and obey the rules and regulations of SF Gym, and that I will follow the instructions and directions of SF Gym during athletic activities;
  6. That I will inform SF Gym immediately should I feel any pain, discomfort, fatigue, nausea or other symptoms that I may suffer during and immediately after athletic activities.
  7. That I may stop participating at any time and that I may be directed to stop by SF Gym should I display noticeable signs of distress.
  8. That I consent to receive first aid and medical treatment by the SF Gym in the event of an accident, injury or illness during athletic activity.
  9. That SF Gym may videotape, audiotape, or photograph you for instructional and promotional purposes without payment of any kind to you and without further notice to you or permission from you.

WARNING: THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR RIGHTS

Agreement for participating in training with SF Gym.

The Trainer refers to the Australian Registered Business SF Gym.

The Activity refers to the participation in strength, fitness and conditioning training and general advices.

  • I acknowledge that it is a condition of participating in this activity that I do so at my own risk.
  • I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees, sponsors, promoters and any person or body directly and indirectly associated with the Trainer, against all liability (including liability for their negligence and the negligence of others) claims, demands and proceedings arising out of or connected with my participation in this activity.
  • If I bring children with me I accept all risks and indemnify and release the trainer, their agents, affiliates, employees, sponsors, promoters and any person or body directly and indirectly associated with the Trainer, against all liability (including liability for their negligence and the negligence of others) claims, demands and proceedings arising out of or connected with the children being present and agree to keep them in the designated areas.
  • This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and assigns
  • I acknowledge that participating in this activity may involve a risk of serious injury or even death from various causes including: over exhaustion, dehydration, equipment failure and accidents with equipment and surroundings
  • I recognise the difficulties associated with the activity and attest I am physically fit to participate safely in this activity and that a qualified medical practitioner has not advised me otherwise
  • I understand the demanding physical nature of this activity. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health if I participate in this activity my Trainer will immediately informed. By continuing to participate in this activity, I accept the risks despite these conditions and am still, and will always be under the terms of this agreement
  • I give consent to the Trainer to use imagery and media for the promotion of their business and website
  • I certify that I am 18 years or older and have read this document and fully understand it

OR

  • As a parent or guardian of the participant (a) I agree to the above for myself and on behalf of the participant and (b) I indemnify and will keep indemnified any person or body directly or indirectly associated with the conduct of the activity on the terms referred to

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT

In consideration of SF Gym, allowing me to participate in SF Gym Athletic Activities, and for other good and valuable consideration, the receipt and sufficiency of which is acknowledged, I hereby agree as follows:

  1. TO WAIVE ANY AND ALL CLAIMS that I have or may have in the future against SF Gym and their owners, volunteers, directors, officers, employees, trainers, instructors, agents, officials, independent contractors, servants, representatives, successors and assigns (all of whom are hereinafter referred to as the RELEASEES) and TO RELEASE THE RELEASEES from any and all liability for any loss, damage, expense or injury including death that I may suffer or that my next of kin may suffer as a result of my participation in climbing and transportation activity, DUE TO ANY CAUSE WHATSOEVER, INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, ON THE PART OF THE RELEASEES, AND INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS AND HAZARDS OF ATHLETIC ACTIVITIES;
  2. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any property damage or personal injury to any third party resulting from my participation in Athletic Activities;
  3. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any costs they may incur for medical costs, emergency transportation, and litigation resulting from my participation in Athletic Activities;
  4. That this Agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, assigns and representatives, in the event of my death or incapacity;
  5. This Agreement and any rights, duties and obligations as between the parties to this Agreement shall be governed by and interpreted solely in accordance with the laws of WA Australia and no other jurisdiction; and
  6. Any litigation involving the parties to this Agreement shall be brought solely within WA and shall be within the exclusive jurisdiction of the Courts of WA.

In entering into this Agreement I am not relying on any oral or written representations or statements made by SF Gym with respect to the safety of athletic activities other than what is set forth in this Agreement.

I CONFIRM THAT I AM THE FULL AGE OF EIGHTEEN (18) YEARS AND I HAVE READ AND UNDERSTOOD THIS AGREEMENT PRIOR TO SIGNING IT, AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, ASSIGNS AND REPRESENTATIVES MAY HAVE AGAINST SF GYM.

Privacy and protection of information: WE WILL NOT SELL OR RELEASE YOUR PERSONAL INFORMATION.

I certify that the above information is true and correct.I agree that if I am a director/shareholder (owning at least 15% of the shares) of the Client I shall be personally liable for the performance of the Clients obligations under this contract.

This agreement must be completed in full andsigned prior to participating in any SF Gym athletic Activities.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
Third Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
Fourth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
Fifth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
Sixth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
Seventh Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
Eighth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
Ninth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
Tenth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
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

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 Medical History
Heart Attack*
No
Yes - please outline below
Heart Surgery*
No
Yes - please outline below
Heart Conditions*
No
Yes - please outline below
Stroke*
No
Yes - please outline below
Chest Discomfort with Exertion*
No
Yes - please outline below
Unreasonable breathlessness*
No
Yes - please outline below
Dizziness, fainting or blackouts*
No
Yes - please outline below
Musculoskeletal Problems*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.
Taking Prescription Medications*
No
Yes - Please outline below
Taking any other medications, pills or supplements*
No
Yes - please outline below
Pregnant*
No
Yes
Trying to conceive*
No
Yes
Male, over 45 years*
No
Yes
Postmenopausal*
No
Yes
Smoker*
No
Yes
Have high blood pressure*
No
Yes - please outline below
Taking blood pressure medication*
No
Yes - please outline below
Have high cholesterol*
No
Yes - please outline below
Have a family history of heart attack*
No
Yes - please outline below
Diabetic*
No
Yes - please outline below
Asthma*
No
Yes - please outline below
Physically inactive*
No
Yes - please outline below

If you answered yes to any of the above, please outline here.

Do you have any other medical conditions that may prevent you from exercising? If so please explain

Do you have any injuries that may prevent you from exercising, if yes please explain

Have you had any injury in the past 2 years that is training or non-training related. It is our duty of care to ask about injuries and for your own safety. Disclosure will not prevent you from training at SF Gym. Please type NIL if the above doesn't apply to you. *
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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