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Physical Activity Readiness Questionnaire / Waiver

Informed Consent / Assumption of Risk:

I am aware that there are significant risks involved in all aspects of physical training. I understand that the reaction of the heart, lungs and vascular system to exercise cannot always be predicted with accuracy. I understand that there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart rate; chest, arm or leg discomfort; transient light-headedness or fainting; and in rare instances, heart attack, stroke or even death. Excessive work can result (in rare cases) 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. While this type of injury is relatively rare, it can occur due to a number of factors, including (but not limited to) genetic predisposition or dehydration, that may be beyond the control of my trainer. I understand that the programs and classes offered by CrossFit RVA LLC are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. These 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. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s).

PAR-Q & Informed Consent / Waiver

I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in CrossFit RVA LLC 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 CrossFit RVA LLC. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in CrossFit RVA LLC programs/classes.

By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive, physical exercise. By signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including, but not limited to, abnormal blood pressure, rhabdomyolosis, fainting, heart attack, or death. By signing this document, I assume all risk for my health and well-being and hold CrossFit RVA LLC, as well as its owners, employees, and other authorized agents including independent contractors, harmless there from. I understand that questions about exercise procedure and recommendations are encouraged and welcome.

Waiver and Release: I fully understand that my personal exercise program may be strenuous and I choose to participate voluntarily. I accept all responsibility for my health and any results, injury or mishaps that may affect my well-being or health in any way. I waive any claims, demands, causes of action or any claims for relief whatsoever against, and release CrossFit RVA LLC (as well as any of its owners, employees, or other authorized agents, including independent contractors) from any and all liability, claims and/or causes of action that I may have for injuries or other damages, arising out of participation in CrossFit RVA LLC activities, including, but not limited to the personal training / nutritional programs and programs/classes.

Photo/Video Release: I hereby grant CrossFit RVA LLC permission to use my photograph/video image in any and all publications for CrossFit or CrossFit RVA LLC, including web site entries, without payment or any other consideration in perpetuity. I hereby authorize RVA LLC to record, edit, alter, copy, exhibit, publish or distribute collectively, “Use” all photos and images. I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my photo appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph or video images. I hereby hold harmless and release and forever discharge CrossFit RVA LLC from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of on behalf of my estate which may have or may have by reason of such Use or this authorization.

Indemnification: I recognize that there is risk involved in the types of activities offered by CrossFit RVA LLC. Therefore I accept financial responsibility for any injury that I may cause either to myself 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 RVA LLC, 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 RVA LLC.

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.

I have carefully read this Agreement and fully understand its contents. I am aware that this is a release and waiver of liability and sign it knowingly, voluntarily, and of my own free will.

Dated: November 14, 2019

First Participant's Name

First Name*

Last Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
Third Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
Fourth Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
Fifth Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
Sixth Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
Seventh Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
Eighth Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
Ninth Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
Tenth Participant's Name

First Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
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*

Last Name*

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

Cell Phone #:

How did you hear about us?

Physical Activity Readiness Questionnaire

1. 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

If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?*
No
Yes

If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes

If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes

If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*
No
Yes

If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes

If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?*
No
Yes
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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