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Revival Strength • Marcus Filly Professional Health and Fitness Coaching

Physical Activity Readiness Questionnaire / Waiver

WAIVER AND RELEASE OF ALL LIABILITY

Informed Consent / Assumption of Risk:

  1. I understand that there are significant risks involved in all aspects of physical training and if I choose to proceed with such training, I voluntarily assume these risks and any injury, loss or damage that may result.
     
  2. I understand that the owners, members, managers, partners, employees and agents of Revival Strength and Marcus Filly Professional Health and Fitness Coaching (collectively and including Marcus Filly, the “Filly Companies”) are not physicians nor are they trained in medicine and they cannot provide reliable advise for any condition I may have. I understand that I need to consult a physician if I have any questions concerning my health or ability to participate in any of the physical training, exercise, classes or services that the Filly Companies offer.
     
  3. I understand that the reaction of the body, including the heart, lung and vascular systems, to exercise cannot always be predicted with accuracy and that there is a risk of a full range of injuries, from minor to severe, including the possibility that I might suffer permanent serious injury or death. I understand that the programs and services offered by the Filly Companies are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. These risks of injury, loss or damage might result from my own actions or negligence, or the actions or negligence of others, or the conditions of the premises or of any equipment used. I acknowledge that there may be other risks to me that are not known or not reasonably foreseeable. I agree to accept and assume all of the above risks that arise as a result of my participation, including property damage, personal injury or death. I also release, waive, discharge, and promise not to sue Filly Companies or its or their owners, managers, members, partners, employees, officers, directors, agents, landlords, affiliated companies, and insurers from any and all liability for injury, loss or damage to my person or property, or any other consequence in connection with my participation in training or rehabilitation services received at or directed by the Filly Companies. 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.
     
  4. I also agree to indemnify, defend and hold harmless the Filly Companies, their owners, managers, members, partners, employees, officers, directors, agents, trainers, affiliated companies, and insurers from any and all damages, liabilities, fees and costs incurred in connection with any third party claims or threats of claims asserted arising from my participation in recreational or athletic activities or rehabilitation services. I intend this release and hold harmless agreement to forever bind myself as well as my estate, personal representatives, guardians, conservators, heirs, executors, administrators, next of kin, and assigns.


​I acknowledge and agree that I have not been solicited or induced or influenced by Marcus Filly or by anybody acting in concert with Marcus Filly to exercise at or under the direction of any of the Filly Companies.

By my signature below, I represent that I have carefully read, understand, and consent to the terms of this waiver and release or liability. I understand and confirm by signing this waiver and release that I expressly and willingly agree to assume complete responsibility for any injury to my person or damage to my property that may arise in connection with my participation in training or exercise received at or directed by the Filly Companies.

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: September 21, 2019

First Client's Name

First Name*

Last Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

First Client's Signature*
Second Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Third Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Fourth Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Fifth Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Sixth Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Seventh Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Eighth Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Ninth Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Tenth Client's Name

First Name*

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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive free workouts and training resources by email
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about us?

How did you hear about us? *
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

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

If YES, Explain:
8. Are you pregnant?*
No
Yes
If YES, has your doctor authorized the form of exercise that you intend to engage in at Revival Strength or under the direction of Marcus Filly Professional Health and Fitness Coaching (collectively, the "Filly Companies")?

**Certain training and exercise at or under the direction of the Filly Companies is very strenuous and challenging beyond that which is offered at other gyms or exercise classes or training programs. It is strongly recommended that you consult your doctor if you have any concern about your ability to perform the exercise that you intend to engage in. 

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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