Loading...

Waiver for Agatsu NC

Informed Consent and Waiver

Today's Date: April 25, 2019

In consideration of entry into training with Moxie Movement LLC DBA Agatsu NC, 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 Moxie Movement LLC DBA Agatsu NC, 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 Moxie Movement LLC DBA Agatsu NC, 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: 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 in length.

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.

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.

Class Reservation and Cancellation Policies:

For small group classes, your spot must be reserved via the designated software reservation system (currently Zen Planner). Please be considerate of your fellow members by only reserving spots for classes you intend to attend.

If a class does not have anyone signed up, it may be canceled by the teacher. Please reserve your spot as soon as possible in order to prevent this.

Classes may be canceled up to one hour prior to start time. If you wish to cancel your attendance in a class, please do so greater than one hour before start time or you will be unable to cancel.

Personal Training Cancellation Policies:

Clients are asked to call 24 hours in advance of the scheduled training session. You will be charged for appointments canceled with fewer than 24 hours notice. Failure to contact your trainer will result in a session loss.

PRICING AND REFUND POLICIES

  • Please note that our punch cards have expiration dates on them. 5-class passes expire two months from purchase, and 10-class passes expire three months from purchase. Please use the classes before their expiration

  • None of our memberships require contracts.

  • After 5-Jan-2018, all new members will also be charged a $25 enrollment fee.

  • Full refunds are only available within 48 hours of purchase, if the membership has not been used at all.
  • Beyond 48 hours, Agatsu NC will refund a maximum of 50% of the purchase price if unused. If the membership has been partially used, we will refund a maximum of 50% of the remaining amount.
  • If you are purchasing a monthly recurring membership, you may cancel at any time with no cancellation fee. If you need to cancel, please email info@agatsunc.com with a clear request to cancel. Cancellation date will be upon completion of the month of the request.
  • We will not refund previous months of a membership just because you did not use them or because you “meant to” cancel earlier.
  • If you purchased one membership but later decide that you wanted a different one, please finish the current membership first, then purchase a new one.
  • Agatsu NC does not offer refunds on any packages that have expired. We cannot extend memberships after their expiration. Please choose a package that you will use prior to the indicated expiration date.
  • Discounts are available on a case-by-case basis for additional family members. We do not offer standard private discounts.

These policies exist for several reasons:

  • We are a small local business, and we wish to spend the majority of our time on coaching as opposed to sitting at a desk making adjustments to memberships.
  • We want to keep membership prices as low as possible, and the quickest way to raise our costs is to increase admin time. Maintaining these policies decreases our admin time.
  • We provide a wide variety of membership options to suit your needs. We also do not require contracts. This allows you to pick what’s the best fit for you.
  • At Agatsu NC we like to practice mindset, personal responsibility, and other aspects of individual philosophy that can better one’s life. As such, we expect our members to be thoughtful about their purchases.

Some packages are cheaper per class because they require less administrative involvement. Please choose the membership that best suits your needs, and that you are willing to adhere to.

Your health and well-being is an investment, and should be approached as such.

We’ll do our best to provide a wide variety of membership options, keep prices as low as possible, and of course provide top-notch coaching. In exchange, please be mindful to understand your membership and the policies of the gym.

 

Please select who will be participating...
AdultMinor
Continue
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver