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Medical Waiver, Client Information, and Terms Agreement {2016}

Hello! Thank you for your interest in becoming a “Rebooter” … Please complete the form below prior to attending class. This information is required annually from each client for liability insurance purposes. Completing the form entitles you to one FREE visit to our Dacula boot camp class! We hope to see you soon :)

Client Information

Client Full Legal Name - First, MI, Last (required):

Date of Birth (required):

Height - Feet-Inches (required):

Home Phone:

Mobile Phone:

NOTE: Class updates and short-notice cancellations due to inclement weather or other circumstances are sent via text message if we have your mobile number on file. These updates can also be found on our Facebook page and Twitter profile so be sure to enable notifications when you like or follow us!

Email Address (required):

Emergency Contact (required):

Emergency Contact - Relationship to Client (required):

Emergency Contact Telephone (required):

 

Image Liability Release

I ACKNOWLEDGE THAT AT TIMES DURING MY MEMBERSHIP, FITNESS REBOOTED MAY CAPTURE IMAGES OF OR INCLUDING ME. I PROVIDE AUTHORIZATION TO USE THESE IMAGES IN MARKETING MATERIALS INCLUDING BUT NOT LIMITED TO ONLINE AND PRINT MEDIA. I RELEASE AND ABSOLVE FITNESS REBOOTED FROM ANY LIABILITY SHOULD THE USE OF THESE WORKS ADVERSELY AFFECT ME PERSONALLY OR PROFESSIONALLY. I DO NOT AUTHORIZE THE SALE OF THESE IMAGES.

INITIAL (required):

 

Medical History

ALL INFORMATION IS CONFIDENTIAL! Please do not leave any field empty. If anything is not applicable, please indicate with “NONE.” ALL fields are required! This information will be provided ONLY to medical personnel in the event of an emergency.

1. If you regularly take any prescription and/or over-the-counter medication on a permanent or semi-permanent basis OR are currently taking any prescription and/or over-the-counter medication for a temporary condition, please list them and the purpose.

2. If you have ANY allergies or drug sensitivities, please provide detailed information regarding all allergies including severity and necessary history pertaining to past allergic reactions:

3. Have you ever had an epileptic seizure or been informed that you might have epilepsy? If so, please explain below:

4. Have you ever been treated for diabetes or any form of anemia, including sickle cell? If so, please indicate the type as well as the treatment:

5. Do you currently have or have you ever had high blood pressure? If so, list any medication that you take regularly as part of your treatment.

6. If you have been diagnosed with asthma, please list all medications you take regularly for treatment:

7. Are you aware of or have you been diagnosed with any condition, ailment, disease, or disorder that could potentially prevent you from physically being able to participate in boot camp activities or that could present a medical emergency? If so, have you obtained a clearance from your physician to participate in this type of exercise program?

8. Do you have any unaddressed medical concerns that could increase your risk of injury?

9. Additional pertinent details regarding ANY existing and/or known health condition not disclosed previously:

 

Waiver of Liability, Risk and Indemnity Agreement

IN CONSIDERATION of being permitted to participate in any way in any event ("Activity") at any time during the current calendar year I, for myself, my personal representatives, assigns, heirs, and next of kin:

1. ACKNOWLEDGE, agree, and represent that I understand the nature of the Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the conditions to be unsafe, I will immediately discontinue further participation in the Activity;

INITIAL (required):

2. FULLY UNDERSTAND that this activity INVOLVES RISKS and DANGERS OF BODILY INJURY.

INITIAL (required):

3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their administrators, directors, agents, officers, members, volunteers, employees, other participants, officials, rescue personnel, sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted (each of the aforementioned shall be considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, INJURIES, OR DAMAGES ON MY ACCOUNT OR TO MY PERSON;

INITIAL (required):

4. I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I further understand that, if applicable, in allowing my minor child to participate in these activities, these terms and waivers apply wholly and completely to him/her as well AND I AM SIGNING THIS ON HIS/HER BEHALF WITH FULL KNOWLEDGE AND UNDERSTANDING that I am personally responsible as parent or legal guardian for ANY AND ALL RISKS AND DANGERS INVOLVED as I agree to absolve all sanctioning organization(s), employees, participants, and members including but not limited to Kathleen Robertson, Fitness Rebooted, and the Gwinnett County Board of Commissioners of all liability;

INITIAL (required):

5. UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS WAIVER AND HAVE SIGNED IT FREELY, WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. I INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

INITIAL (required):

Full Legal Name of Client (required):

Full Legal Name of Client's Parent or Legal Guardian (required if under 18):

I agree to all terms as they are stated. I further attest to the truthfulness of all information and data provided and submit this data warranting that nothing has been omitted. I understand that not disclosing information or withholding important personal history prevents the trainer from being able to properly advise the client and could increase the potential risk.

NOTE: Clients attending the on-location group fitness boot camp will be required to provide their signature on this form. It will be printed and presented to you at your first class and added to your client profile. You will be required to provide a valid form of photo identification upon signing.

I understand that if at any time I attend assessments at any on-location boot camp facilitated by Fitness Rebooted that it is MY responsibility to notify the trainer if I have a cardiac pacemaker or any other implanted medical devices as well as if I am pregnant or trying to become pregnant EVEN IF THOSE CONDITIONS ARE INCLUDED ELSEWHERE IN THIS WAIVER as these conditions will be negatively impacted by the electronic body fat monitoring tools used by boot camp staff.

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