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Waiver for Structure Strength, Legitimate Movement, and BodyWork.

Informed Consent and Waiver

Today's Date: December 12, 2018

In consideration of entry into training with Legitimate Movement (Structure Strength and Conditioning, LLC) and Body Work with Kevin Perrone, I the undersigned intend to be legally bound and do hereby agree to be legally bound for myself and for all successors in interest I may have, by this Contract, Waiver and Release of Liability, and hereby agree to hold harmless and indemnify Legitimate Movement, Structure Strength and Conditioning, LLC, and Kevin Perrone, as well as all officers, members, employees, assistants, volunteers, assigns, or agents of any type whatsoever acting on or in behalf of the aforementioned entities and persons, against any claims for damages or other claims for injuries or losses of any kind suffered by me or any others, directly or indirectly, arising out of any practice, instructions, or other activity related to this program as well as participation in this program or traveling to or from this program or any other activity related to this program.

I understand that the activities, exercises and training methods to be taught may not be appropriate for all people and may, in some cases, cause injury or aggravate existing injuries. I certify that I am physically able to participate in this activity and will further hold Legitimate Movement, Structure Strength and Conditioning, LLC, and Kevin Perrone, as well as any and all officers, members, employees, assistants, volunteers, assigns, or agents of any type whatsoever acting on or in behalf of the aforementioned entities and persons, harmless for any injury sustained in the course of this training due to any physical defect or condition that I may have, whether now known or hereinafter discovered. I further acknowledge that in consideration for this training, this release shall not expire and shall be considered effective in perpetuity. I also understand that all exercises, training methods and concepts are to be used at my own risk and that the aforementioned trainers and entities assume no responsibility for my actions.

I acknowledge if I am uncomfortable with any activity, exercise or training program within the course that I may immediately state so, and that it is my right and responsibility to remove myself from the situation immediately and that I am encouraged to do so.

I have understood all that is expressed in this waiver and release of liability, and I certify that I am of sound judgment, legally competent to agree to this waiver.

Additionally, I certify that I am / am not (check one) eighteen years of age or older, or a legally emancipated adult.

PAR-Q & Medical Clearance:

A medical clearance form is required of all participants who answer "yes" to any of the seven PAR-Q questions. Note: Personal training and Body Work staff reserve the right to require medical clearance from any client they feel may be at risk.

Session Duration:

All personal training sessions are one hour. At request, personal training sessions may also be 30 minutes in length and will count for half of a session (not applicable on a Personal Training Introduction Purchase, Single Session purchase or Partner package purchases). Small group class sessions will be one hour and 15 minutes in length. Body Work sessions with Kevin Perrone will vary in length of time - as scheduled individually.

Attire:

Come prepared to each training session in proper workout attire (shorts, gym pants, T-shirt). Shoes are optional and left up to the discretion of the participant. Participants arriving unprepared for their training session may lose the session. For Body Work sessions, wear proper attire as discussed with Kevin Perrone.

Late Policy:

Clients are responsible for arriving on-time to their sessions.

Trainers are obligated to wait only 10 minutes. After 10 minutes, the trainer is not required to lead the remaining time of the session and the session may be lost.

For small group classes, attendees are expected to arrive before the designated start time. Please respect your coaches and fellow members by not being late.

Cancellation Policy:

Clients are asked to call 24 hours in advance of the scheduled training session. You will be charged for appointments cancelled with fewer than 24 hours notice. Failure to contact your trainer will result in a session loss. Missed sessions due to trainer absence will be rescheduled for 10 days prior to or following a missed session.

Class Reservation Policy:

For small group classes, your spot must be reserved via the designated software reservation system (currently Zen Planner) no later than one hour prior to class start time. Please be considerate of your fellow members by only reserving spots for classes you intend to attend.

Body Work Sessions:

I understand that Kevin Perrone is a Licensed Massage and Bodywork Therapist and that any bodywork performed on myself is totally voluntary and may be refused at any time, even if the session has already begun. I understand it is my responsibility to relate any pain or discomfort experienced and that Kevin Perrone intends to work within individual client tolerance. I understand that anything is possible during and following a bodywork session including but not limited to: bruising, pain, swelling, discomfort, emotional or psychological changes, dizziness, and nausea. I understand that all bodywork or massage work is meant to be therapeutic in nature only.

I understand that it is my responsibility to inform Kevin Perrone of all medical issues during the health history interview. I understand that the session is not a replacement for medical evaluation and it is not Kevin Perrone's duty to diagnose any medical conditions. All interactions before, during, and after the session are intended to be informative in nature and are not to replace or supersede any previous or future medical advice.

Any recommendation for changes in diet including the use of food supplements, weight reduction and/or body building enhancement products are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes. You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death. I am also not responsible for any loss of your personal property.

I am forewarned that Kevin Perrone will not in any event, provide medical and/or hospitalization insurance for my benefit, and in the event of an injury to my person occurring either as a result of my being on any portion of the location in which a session is being conducted. I will save harmless and keep indemnified Kevin Perrone and his respective trustees, beneficiaries, staff, and officers from and against any and all action claims, costs, expenses or demands, in respect of such injury or injuries, including death, howsoever caused, arising out of or in connection with my use of any facilities or my being on any portion of said premises and notwithstanding that the same may have been contributed to or occasioned by the negligence of Kevin Perrone and his representatives, officers, directors, trustees and or beneficiaries.

 

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

Height: *

Weight: *
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

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical Questionnaire
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes

When was your last physical check-up at your current family/walk-in doctor?

Please check any of the conditions you have had, or are experiencing

Anemia
Ankle Swelling
Any Vascular Diseases
Asthma, Emphysema, Bronchitis
Back/Neck Pain
Broken Bones
Bursitis
Cancer
Chronic Bruising
Chronic Cold or Flu
Diabetes
Dizziness/Light-Headedness
Drug Allergies
Eating disorder
Emotional Disorders
Epilepsy
Eye Problems
Fibromyalgia
Headaches
Hearing Loss
Heart Attack
Heart Condition
Hepatitis
Hernia
High Cholesterol
High/Low Blood Pressure
Irregular Heart Beat
Insulin Resistance
Jaw Pain
Migraines
Motor Vehicle Accidents
Muscle Pain
Muscle Tension
Orthopedic Problems/Arthritis
Polycystic Ovary Syndrome
Pregnancy/Planning Pregnancy
Recent Hospitalization
Sciatica
Severe Menstrual Cramps
Smoking
Strains/Sprains
Stress
Stroke
Surgeries
Tendonitis
Thrombosis
Thyroid Problems
Tingling/Numbness
Ulcer
Unusual Shortness of Breath
Varicose Veins
Whiplash
Other

If Other, please list:

Do you have pain or have you injured or had surgery on any of the following areas:

Neck
Upper Back
Lower Back
Shoulder (Left)
Shoulder (Right)
Elbow (Right)
Elbow (Left)
Wrist (Right)
Wrist (Left)
Hip (Right)
Hip (Left)
Ankle (Right)
Ankle (Left)
Knee (Right)
Knee (Left)
Other

If Other, please list:

How long have these pains occurred?

Have you previously sought medical help for these pains?

Do you have regular treatment from any of the following individuals?

General Practitioner (annual)
Chiropractor
Massage Therapist
Physiotherapist
Acupuncturist
Naturopath

If Naturopath, Current Activity Levels:

Do you know of any other reason why you should not do physical activity?

Do you consider yourself to be active? How often do you exercise? Please describe your exercise program.

Have you ever worked with a personal trainer or in a group fitness class? Please give us details.

Injuries and Surgeries

Date and Any Important Details

Medications/Supplements

Reason for Taking the Medications/Supplements

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

Height: *

Weight: *
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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