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[FITNESS, SPORTS & RECREATION] Crossfit / Fitness Class New Client Intake + Packages

[FITNESS, SPORTS & RECREATION] Crossfit / Fitness Class New Client Intake + Packages

Please complete all of the information below. Be sure to read and sign the waiver!

Phone: (123) 456-6789
  • crossfit rope
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  • Please select the best answer for each question below: *
      Yes No
    Have you ever had any form of heart disease?
    Have you ever experienced shortness of breath or chest pains?
    Do you have high blood pressure?
    Do you smoke?
    Do you have diabetes?
    Family history of heart disease?
    Do you currently exercise at least three times per week?
  • Please read the following waiver carefully as it is specific to [ENTER ORGANIZATION NAME]

    As a participant at [ENTER ORGANIZATION NAME] , I understand and I have been informed that my voluntary participation in fitness programs and special events including, but not limited to, the use of weights, number of repetitions and use of any and all equipment, all apparatus designed for exercising and the associated facilities shall be the participants sole responsibility during all times of fitness training participation and use. I also understand and have been informed that participation in any of the events noted above does pose the risk of serious injury or other adverse health consequences, including death. I agree to self limit my exertion through good judgment and to terminate any physical activity immediately, if it exceeds my personal limitations, whether or not it exceeds the activity level recommended by the staff or prescribed by my physician. I hereby consent to, and permit emergency medical treatment in the event of any injury or illness.

    If requested to obtain written consent from a personal physician or other health care practitioner, I verify that I have been evaluated by that practitioner, and I have been approved to participate in the programs and exercise activities. I understand it is my responsibility to seek and to continue to receive medical evaluations from my personal physician and other health care practitioners to determine if there are any medical conditions or injuries that could limit my participation in fitness or health promotion activities. I agree to notify the staff of changes in health status, physical injuries, pregnancy, hospitalizations, surgery or additional physical and medical limitations, or additions/changes in medication recommended by my physician that may affect my participation in fitness or health promotion activities. I understand that for any new medical conditions or injuries noted above, written consent from my personal physician may be required prior to resuming activities.

    If my current fitness or injury status limits my activities, I agree to follow the recommendations for modification as stated by my health care practitioners and/or trainers. These limitations have been fully explained to me, and I understand and assume the risk of injury and other adverse health consequences, including death, if I exceed the exercise and dietary guidelines recommended by my consulting practitioners. I agree that non-compliance may result in the termination of my entitlement to train at [ENTER ORGANIZATION NAME].

    In consideration for my participation in fitness programs, special events, and exercise activities, I voluntarily assume the risk of any injury, loss and/or adverse health consequence. I for myself, my heirs, executors, administrators and assignees, hereby release [ENTER ORGANIZATION NAME] and their officers, directors, employees and their affiliated entities from any and all claims, liabilities or demands of any kind arising from any injury, loss or adverse health consequence, including death, related to my participation in fitness or health promotion activities, except to the extent resulting from its or their negligence or willful misconduct.


    I authorize [ENTER ORGANIZATION NAME], or its representatives to use, reproduce, and/or publish photographs and/or video that may pertain to me—including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors, and waive any rights of compensation or ownership thereto. This material may also appear on the [ENTER ORGANIZATION NAME] website or web pages. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently [ENTER ORGANIZATION NAME] may publish materials, use my name, photograph, and/or make reference to me in any manner that the Corporation or project sponsor deems appropriate in order to promote/publicize service opportunities.
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