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Virtuosity Fitness
d/b/a CrossFit Bradenton

34203 59th Drive East, Unit 104
Bradenton, FL 34203

 

Waiver & Health Info

Photography/Video Release

Participants involved in any activities offered by CrosssFit Bradenton may be photographed or videotaped during training. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the CrossFit Bradenton website or any editorial, promotional or advertising material produced and/or published by CrossFit Bradenton.

Waiver and Release of Liability

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. I acknowledge and accept that upon entering the premises of Crossfit Bradenton that I am a participant no matter what I am or am not personally involved in. Risks include, but are not limited to: falls 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; strains and sprains. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or any other participants. I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity, competition or class while at, or under direction of CrossFit Bradenton, their trainers, owners and fellow participants.

I acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others.

Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by CrossFit Bradenton, I, the undersigned, hereby release CrossFit Bradenton, their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, rise out of, or are in any way connected with my participation in CrossFit Bradenton activities, including those allegedly attributed to the negligent acts or omission 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 CrossFit Bradenton 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.

Indemnification: The participant recognizes that there is risk involved in the types of activities offered by CrossFit Bradenton. Therefore the participant accepts financial responsibility for any injury that 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 attorney=s 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 CrossFit Bradenton, 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 CrossFit Bradenton at the main building or abroad. This includes but is not limited to parks, recreational areas, playgrounds, areas adjacent to main building, and/or any area selected for training by CrossFit Bradenton.

I have read and understood 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.

Date: August 17, 2018

First Participant's Name

First Name*

Last Name*

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

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
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*
Check to receive information, news by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
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*

Last Name*

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

How did you hear about us?

Health Questions

Do you:
Smoke?*
No
Yes
Drink alcohol?*
No
Yes
Take prescription meds?*
No
Yes
Are you exercising now?*
No
Yes

How much per week?
Do you play sports?*
No
Yes

Do you have:

Back pain, Knee pain or Shoulder pain?*
No
Yes
Previous Injuries or Surgeries?*
No
Yes
High blood pressure, Asthma, Diabetes, or a Heart condition?*
No
Yes
Any other health conditions not listed?*
No
Yes

Please List any injuries, surgeries, or ailments you have or have had in the past:
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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