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Waiver of Liability

In consideration of my participation in CrossFit En Fuego’s personal/group training sessions, CrossFit exercise programs, boot camps, and/or related fitness activities (individually and collectively, the “Activity”), I (please initial) [inital], myself, my heirs, assigns, personal representatives, and if signed by me as a parent/legal guardian on behalf of my child hereby waive, release, forever discharge and covenant not to sue CrossFit En Fuego, its owners, managers, members, employees, partners, sponsors, volunteers, agents, advisers, insurers, cities and/or counties of participation, CrossFit Inc. and Interior Elegance, Inc.(the “Released Parties”) from any and all liability from all claims, actions, suits or other proceedings resulting in personal injury, including death, accident, illness or property damage I may suffer or sustain, regardless of fault, arising from or in connection with my participation in the Activity, the equipment used during the Activity (whether provided by CrossFit En Fuego, a third party or myself) and the buildings, facilities and other grounds where the Activity was located.

(A) I do hereby declare myself physically fit and able to participate in the Activity; I am in good health, and I am unaware of any medical condition which might make my participation inadvisable. Furthermore, I have honestly and completely answered the attached Health Screening Questionnaire.

(B) I have no pre-existing physical limitation or condition which may be aggravated or harmed by my participation in the Activity.

(C) I acknowledge that I have either had a physical examination and have been given my physician’s permission to participate, or that I have decided to participate in the Activity and/or use of equipment without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment and machinery in the Activity.

(D) I fully understand that I may injure myself as a result of my participation in the Activity including, but not limited to: heart attack, muscle strains, pulls or tears, shin splints, knee/lower back/shoulder/foot injuries and any other illness, soreness, or even death.

(E) I understand that I am to immediately cease activity if I feel dizzy, nauseous, faint, or experience shortness of breath, headache, or any other physical symptom which is unusual for me, and shall advise the instructor of any such occurrence.

(F) I agree to perform activities at the intensity level appropriate for my general health, physical condition, and comfort level.

(G) I agree that I have read and received a copy of the En Fuego Rules, Kids’ Room Rules, and CrossFit Kids Rules and agree to abide by them. My signature on this form indicates my understanding and acceptance of the policies and procedures stated on each page.

(H) 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 exceptional rhabdomyolosis. You 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 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/coach. I understand that the programs and classes offered by En Fuego 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: serious injury or death, injury or death due to negligence on the part of myself, my training partner, coach, En Fuego, or other people around me, and injury or death due to improper use or failure of equipment, over-exertion, slip and fall, or an unknown health problem.

(I) I agree to indemnify and hold harmless En Fuego, their principals, agents, employees and volunteers from liability, including punitive damages, attorney’s fees and costs, for the injury or death of any person and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by En Fuego.

(J) I grant En Fuego permission to use my photograph/video image in any and all En Fuego publications, including website entries, social media updates or postings, and advertisements without payment or any other consideration in perpetuity. I grant En Fuego permission to record, edit, alter, copy, exhibit, publish or distribute collectively all photos and images. I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my photo appears. I waive any right to royalties or other compensation arising or related to the use of the photograph or video images.

(K) I acknowledge that I have had the opportunity to ask CrossFit En Fuego’s representatives any questions that I may have about the Activity, and about this waiver of liability. I represent that all such questions have been answered to my complete satisfaction. I further declare that I have had an opportunity to inspect the equipment to be used in the Activity prior to my participation and, based upon my inspection, have found all equipment to be in good condition and in proper working order.

(L) In the event of a legal dispute, I agree to participate in private, binding arbitration. I will be responsible for any attorney’s fees or court costs incurred by myself, my heirs, agents, or successors. Crossfit En Fuego shall have no obligation to contribute to attorney’s fees or court costs. I acknowledge that in the event of a favorable decision/ruling for Crossfit En Fuego I will be responsible for attorney’s fees and court costs incurred by Crossfit En Fuego or its representatives, agents or insurers.

(M) If any portion of this waiver is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.

I understand my signature signifies that I have read and understand all the information on the questionnaire, that I have truthfully, accurately and completely answered all the questions, and that any questions/concerns I may have had have been addressed to my complete satisfaction.

 

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
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
First Name*
Last Name*
Emergency Contact's Phone Number*
f the person whose signature appears above is under 18, I sign the foregoing Waiver of Liability on behalf of my child. I hereby represent that I am the parent/legal guardian of child and have full authority to execute the Waiver of Liability as a parent on behalf of my child, my family, and myself. I also give permission to administer the necessary first aid, 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 medical facility deemed necessary for the well being of the child.


By signing below the parent or court-appointed legal guardian agrees that they are also 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*
Date of Birth
Parent or Guardian's Information
How did you hear about us? *
Have you trained in Crossfit before?*
No
Yes

What are your goals? *

AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire 

Assess your health needs by marking all true statements. 

History - You have had:
A heart attack
Heart Surgery
Cardiac catheterization
Coronary angioplasty (PTCA)
Pacemaker-implantable cardiac defibrillatory/ rhythm disturbance
Heart valve disease
Heart failure
Heart transplantation
Congenital heart disease
Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness, fainting, or blackouts
You take heart medications
Other health issues
You have diabetes
You have asthma or other lung disease
You have burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You take prescription medications
You are pregnant

If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.

Cardiovascular risk factors
You are a man older than 45 year
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal
You smoke, or quit smoking within the previous 6 months
Your blood pressure is 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is 200 mg/dl
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)
You are physically inactive (i.e., you get 30 minutes of physical activity 3 days per week)
You are 20 pounds overweight

If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. 

None of the above

You should be able to exercise safely without consulting your physician or other appropriate health care provider 

Please note: If your health changes so that you then answer YES to any of the above questions, please inform CrossFit En Fuego. Your physical activity plan may need to be adjusted. 

1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?*
No
Yes
2. Do you feel pain in your chest when you do physical activity?*
No
Yes
3. In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Click to customize question*
No
Yes
4. Do you lose balance because of dizziness or do you ever lose consciousness?*
No
Yes
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
6. Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure, cholesterol or heart condition?*
No
Yes
7. Are you currently taking any drugs or medications that affect your blood pressure, balance, or coordination?*
No
Yes
8. Do you know of any other reason why you should not do physical activity?*
No
Yes
If yes, please explain:
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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