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Waiver and Release of Liability
CrossFit Kerosene
1111 Rancho Conejo Blvd Unit 106 and 107
Newbury Park, CA 91320

All activities at CrossFit Kerosene, including any adjoining areas such as the park, street, and sidewalk, are voluntary and entirely at the risk of the individual(s) participating, regardless whether instructors are present or absent. 


Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. 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 me, my training partner, or other people around me, injury or death due to improper use or failure of equipment. I am aware that any of these above-mentioned risks may result in serious injury or death to me and or my partner(s).


I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class at CrossFit Kerosene or anywhere on or near the premises, including the park and surrounding areas and at any and all other locations offered now and in the future.


I willingly assume full responsibility for my children while they are at CrossFit Kerosene. I am aware that they may get injured while playing within the CrossFit Kerosene facility and accept full responsibility for any injury or death that may result from participation in any activity or class at CrossFit Kerosene or anywhere on or near the premises, including the park and surrounding areas and at any and all other locations offered now and in the future. I am aware that I need to walk my children into the facility and to the kids area prior to class start.


The program at CrossFit Kerosene may include extreme physical exertion. By signing this document, you acknowledge that you understand and accept the risks associated with extreme exertion, including dehydration, extreme muscle soreness, muscle and joint pain, temporary metabolic, heart rate, or chemical imbalances (for example Rhabdomyolysis), and other conditions associate with extreme exertion. You also agree to read CrossFit Journal articles and other materials as instructed by Kelley Chantarumporn, Ravee Chantarumporn and Virginia Block or other CFK instructor to increase your knowledge of these risks and that you will take necessary precautions to avoid them. By signing this document, you acknowledge that it is your sole responsibility to avoid extreme exertion and to practice proper and adequate nutrition, hydration, and rest and that CrossFit Kerosene, CrossFit Kerosene staff and instructors, Kelley Chantarumporn, Ravee Chantarumporn and Virginia Block, as trainers, or business owners, are in no way responsible for the effects or after effects of any extreme exertion.


I, the undersigned acknowledge that I have no physical impairments or illnesses that will endanger myself or others.


Release: In consideration of the above mentioned risks and hazards, and all other risks and hazards known to me and conveyed to me by Kelley Chantarumporn, Ravee Chantarumporn and Virginia block, CrossFit Kerosene staff or trainers, participants at CrossFit Kerosene, and conveyed to me in any literature provided to me by CrossFit Kerosene and in consideration of the fact that I am willingly and voluntarily participating in the activities available at CrossFit Kerosene, I, the undersigned hereby release CrossFit Kerosene, Kelley Chantarumporn, Ravee Chantarumporn and Virginia Block,  individually, and in all other aspects from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation with CrossFit Kerosene activities, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties.

This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.


Indemnification: The participant recognizes that there is risk involved in the types of activities offered by CrossFit Kerosene and at the various locations where these activities are offered and that these are enjoined voluntarily and with no commercial intent. Therefore the participant accepts financial responsibility for any injury that the participant may cause either to him/herself or to any other participant due to his/her negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless CrossFit Kerosene, CrossFit Kerosene staff and trainers, Kelley Chantarumporn, Ravee Chantarumporn and Virginia Block, individually and as business owners, from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by CrossFit Kerosene at any location where activities may take place now or in the future.


Activities with CrossFit Kerosene may be photographed or otherwise recorded and will be used for promotional or instructional purposes, including, but not limited to, use on the internet. By signing this document you agree to allow the unrestricted use of your image and voice for these purposes.


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.

Today's Date: May 14, 2025

First Participant's Name

First Name*

Middle Name

Last Name*

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

Work Phone #

Cell Phone #
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Third Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Fourth Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Fifth Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Sixth Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Seventh Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Eighth Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Ninth Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Tenth Participant's Name

First Name*

Middle Name

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

Work Phone #

Cell Phone #
Parent or Guardian's Email Address

Email*

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

In case of emergency, I would like the following person(s) to be called:



Name *

Phone# 1 *

Phone# 2




Name

Phone# 1

Phone# 2

Your personal information will be kept private.

However, it is a prerequisite for members at CrossFit Kerosene to also fill out an Emergency Contact information card. These are kept in the workout area and will be accessible to anyone at CrossFit Kerosene in order to allow any individuals to access the contact information for the purposes or notifying emergency contacts.


**We will not share any of your personal information. All items on this form are for in house use only.**


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(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

Work Phone #

Cell Phone #
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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