Consent Waiver – Legacy Fitness

Name *

First

Last

Date of Birth *

Email any aware

Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Health Assessment

Have you ever had any form of heart disease? *

Yes
No

If YES please explain

Have you ever experienced shortness of breath or chest pain? *

Yes
No

If YES please explain

High blood pressure? *

Yes
No

If YES please explain

Cigarette Smoking? *

Yes
No

If YES please explain

Diabetes *

Yes
No

If YES please explain

Family history of heart disease *

Yes
No

If YES please explain

Do you work out at least 3 times a week? *

Yes
No

If YES please explain

Are you currently taking any medication? *

Yes
No

If YES please explain

Do you have any problems in the following areas? *

If you checked any please explain.

Informed Consent/Assumption of Risk INFORMED CONSENT/ASSUMPTION OF RISK: By checking "Yes" in the check box immediately below this verbiage, I agree to participate in one or more physical fitness program(s)/class(es) sponsored by Legacy Fitness, which may include, but not necessarily be limited to, Legacy Fitness Boot Camp, Legacy Fitness Kids, Training, and/or training of any kind by any affiliate, subsidiary or partnership of Legacy Fitness and/or Brian Yoak (hereinafter collectively referred to as Legacy Fitness). Legacy Fitness made me fully aware that the fitness programs/classes which Legacy Fitness offers and in which I desire to participate are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. I the undersigned recognize and understand that the programs/classes are not without varying degrees of risk which may include, but are not limited to the following: Injury to the musculoskeletal and/or cardio respiratory systems 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, or injury or death due to a medical condition, whether known or unknown by me. I am aware that any of these abovementioned risks may result in serious injury or death to myself and or my partner(s). *

Yes

By checking "Yes" in the check box immediately following this verbiage, I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in Legacy Fitness programs/classes and accept full responsibility for any injury or death that may result from participation in any activity, class or physical fitness program. I herby certify that I know of no medical problems that would increase my risk of illness and injury as a of participation in a fitness program designed by Legacy Fitness. Legacy Fitness informed me that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. Legacy Fitness informed me that these changes could include abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and in very rare instances, heart attack or even death, and I fully understand the same. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in Legacy Fitness programs/classes. *

Yes

RELEASE: By checking "Yes" in the check box that immediately follows this verbiage, you have read and agree with: "In full consideration of the above mentioned risks and hazards and in full consideration of the fact that I am willingly and voluntarily participating in the activities made available by Legacy Fitness, and with my full understanding of all of the above, I hereby waive, release, remise and discharge Legacy Fitness and its agents, officers, principals and employees and volunteers, of any and all liability, claims, demands, actions or rights of action, or damages of any kind related to, arising from, or in any way connected with, my participation in Legacy Fitness programs/classes, 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 Legacy Fitness 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." *

Yes

INDEMNIFICATION: By checking "Yes" in the check box that immediately follows this verbiage, I agree that I recognize that there is risk involved in the types of activities offered by Legacy Fitness. Therefore I accept financial responsibility for any injury that I or 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 Legacy Fitness, 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 Legacy Fitness. *

Yes

Use of picture(s)/film/likeness: By checking "Yes" in the check box that immediately follows this verbiage, I agree to allow Legacy Fitness, its agents, officers, principals, employees and volunteers the picture(s), film and/or likeness of me for advertising purposes. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform Legacy Fitness of this in writing. *

Yes

I have fully read and fully understand 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 checking "Yes" in the check box that immediately follows this sentence that I am waiving valuable legal rights. *

Yes

Please select one or two of the most important improvements you seek through our program: *

General Health & Fitness
Lose Weight and/or Look More Attractive
Become a More Finely-Tuned Athlete
More Confidence, Energy & Focus
Better Quality of Life

Which best describes your current physical condition? *

What is your age range? *

What is your gender? *

Male
Female