Registration and Waiver

I coud not upload this as a pdf to be downloaded.  Cutting and pasting to Microsoft Word seems to work best.
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Garage Gym 307

This agreement must be completed in full, initialed where indicated, dated, signed prior to participating in any Garage Gym 307 athletic activities.

Personal Information

Student (Last, First, MI.)			Birth date	Sex
Address			City	Zip
Parent #1 (Last, First, MI.)	Home Phone #		Work Phone #	Cell Phone #
Parent #2 (Last, First, MI.)	E-mail
How did you      here about us?   (circle)       newspaper              bulletinboard               word of mouth
Insurance		Preferred hospital

Health Assessment

Do you have a family history of heart disease?	Yes / No
Do you have high blood pressure?	Yes / No
Do you have Diabetes?	Yes / No
Do you ever experience dizziness?	Yes / No
Do you have neck problems?	Yes / No
Do you have back problems?	Yes / No
Do you have hip/pelvis problems?	Yes / No
Do you have knee problems?	Yes / No
Do you have any current injuries?	Yes / No
Do you have any allergies?	Yes / No
Are you currently taking any medication(s)?	Yes / No
Are you a smoker?	Yes / No
Are you currently exercising?	Yes / No
Are there any exercises you know you cannot do?	Yes / No
Have you ever participated in strenuous exercise?	Yes / No
Have you any reason not to participate in strenuous exercise?	Yes / No
Have you ever experienced shortness of breath or chest pain?	Yes / No
Previous Medical Condition that might affect their safe participation (Physician’s  release may be required) additional space on  the back.	Yes / No

Assumption of Risk - Release of Liability - Waiver of Claims & Indemnity Agreement

BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE.

Garage Gym 307 Owners, volunteers, Directors, Officers, employees, trainers, instructors, Agents, officials, independent contractors, representatives, successors and assigns (hereinafter referred to as “Garage Gym 307”).

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 myself, my training partner, or other people around me, injury or death due to improper use or failure of equipment. I willingly assume full responsibility for the risks that I am exposing myself or my children to and accept full responsibility for any injury or death that may result from participation in any activity or class while under direction of Garage Gym 307.

Furthermore, I understand there are inherent risks in all aspects of physical training and I acknowledge that I have been informed of the possible strenuous nature of CrossFit training methods and the potential for undesirable physiological results including, but not limited to, abnormal blood pressure, muscle soreness and fainting. I also acknowledge that I have been specifically warned about the medical condition “Rhabdomyolysis” (see next page) and accordingly I have been advised to limit my effort in order to minimize the risks associated with this condition.

(Please Initial: ______

Release of Liability:  In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities available at Garage Gym 307, I, the undersigned hereby release  Garage Gym 307, their principals, agents, employees, and volunteers 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 in this activity, 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. If I am signing on behalf of a minor child, I also give full permission for any person connected with Garage Gym 307 to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.

 (Please Initial: ______ )

Indemnification: The participant recognizes that there is risk involved in the types of activities offered by Garage Gym 307. 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 Garage Gym 307, their principals, agents, employees, and volunteers 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 Garage Gym 307.

(Please Initial: ______)

Consent to use a Photograph or Video:  I give Garage Gym 307 permission to use photographs and/or video of myself or children for the use of media and advertisements which support Garage gym 307.

(Please Initial: ______)

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.

_______________________________________________________   _____________________________

Signature                                   Date

_______________________________________________________    _____________________________

Signature of Parent if participant is under 18 years of age.                                        Date

WARNING… Safety first!!!

High intensity exercise must be approached cautiously in the beginning, a gradual ramp up of intensity is necessary to allow muscles cells to adapt to the new demands being placed on them. Failure to do so, opens the door to a life threatening condition, known as ‘Rhabdomyolysis’. In short, the muscle cells are damaged flooding the bloodstream with toxins that can overwhelm the kidneys as they attempt to cleanse the blood, leading to potential kidney failure. That being said, it is important that you start at a reduced intensity. Brown urine, complete muscle weakness and/or swelling of joints are warning signs of ‘Rhabdo’. If you develop these symptoms, seek medical assistance immediately.