Loading...

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 predicated 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 external rhabdomyolysis. 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 actors, 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 Bull Strong Fitness Center, are of a nature and kind that are extremely strenuous and can/may push me to the limits 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 abovementioned risks may result in serious injury or death to myself 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 Bull Strong Fitness Center, programs/classes and accept full responsibility for any injury or death that may realist from participation in any activity, class or physical fitness program. I nearby 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 Bull Strong Fitness Center. With my fullest understanding of the above information, I agree to assume any and all risks associated with my participation in Bull Strong Fitness Center’s programs classes or events. 

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 result including, but not limited to, abnormal blood pressure, rhabdomyolysis, fainting, heart attack, or death. By signing this document, I assume all risks for my health and well-being and hold Bull Strong Fitness Center, as well as its owners, employees, and other authorized agents including independent contractors, harmless therefrom. I understand that questions about exercise procedure are recommendation are encouraged and welcomed.

I Agree

WAIVER & 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 Bull Strong Fitness (as well as nay of its owner, employees or other authorized agents, including indecent contractors) from any and all liability, claims and/or cases of action that I may have for injuries or other damages, arising out of participation in Bull Strong Fitness Center’s activities, including, but not limited to the personal training/nutritional programs and programs/classes. 

I Agree

PHOTO/VIDEO RELEASE: I nearby grant Bull Strong Fitness Center permission to use my photograph/video image in any and all publications for promotion on social media sites, Bull Strong Fitness Center, including website entries, without payment or any other consideration in perpetuity. I hereby authorize Bull Strong Fitness Center to edit, alter, copy, exhibit publish or distribute all photos and images. I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my phot 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 Bull Strong Fitness from all claims, demands, and cases of action which I, my heirs, representatives, executors, administrators, or any other persons, action on my behalf of on behalf of my estate which may have or may have by reason of this authorization. 

I Agree

INDEMNIFICATION: I recognize that there is a risk involved in the types of activities offered by Bull Strong Fitness Center. 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 Bull Strong Fitness Center, their principals, agents, employees, and volunteers from liability for injury or death of any person(s) and damage to property that my result from my negligent or intention act of omission while participating in activities offered by Bull Strong Fitness Center. I have fully read and fully understand the foregoing assumption of risk and release of liability and I understand that by signing it obliges me to indemnify the parties named for any liability for injury of 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 Agree

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

June 20, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

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

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 by *
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:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

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 by *
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:
Third Participant's Name

First Name*

Middle Name

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

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 by *
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:
Fourth Participant's Name

First Name*

Middle Name

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

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 by *
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:
Fifth Participant's Name

First Name*

Middle Name

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

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 by *
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:
Sixth Participant's Name

First Name*

Middle Name

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

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 by *
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:
Seventh Participant's Name

First Name*

Middle Name

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

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 by *
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:
Eighth Participant's Name

First Name*

Middle Name

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

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 by *
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:
Ninth Participant's Name

First Name*

Middle Name

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

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 by *
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:
Tenth Participant's Name

First Name*

Middle Name

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

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 by *
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:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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:*
Emergency Contact

First Name*

Last 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.


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*

Middle Name

Last Name*

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

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 by *
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:
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 - TRY IT FREE!