Waiver, Release, and Assumption of Risk Form



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Date: ___________

Name: __________________________________________

Address:_______________________________________City:________________Zip:_________

Home phone: _________________________ Cell phone: ______________________ Email Address:_____________________

Date of Birth:_____________________

In case of emergency: Name:__________________________ Phone:______________________

1. Has your doctor ever said you have heart trouble, heart palpitation, coronary artery disease, or high blood pressure? ________

2. Do you frequently experience pain or discomfort in the chest or heart area? _____

3. Do you have a bone or joint problem that could be made worse by a change in your physical activity?________

4. Do you suffer dizziness or fainting? ______

5. Do you have any difficulty breathing? _______

6. Do you suffer from swollen ankles (due to circulation problems or metabolic condition? _______

7. Do you suffer from shortness of breath at rest or upon mild exertion? ______

8. Do you know of any other reason why you should not engage in physical activity? _____

(If “yes” is the answer to any of the above please have physician complete medical clearance form prior to exercise)

1. Has a physician ever diagnosed you as having high blood pressure (>160/90), or are you on blood pressure medication?

2. Do you suffer from High cholesterol? _______

3. Do you smoke? _____ If yes, how many cigarettes per day? ________

4. Do you suffer from diabetes? ______

5. Has anyone in your family suffered from coronary or atherosclerotic disease prior to the

age of 55 yr.? __________

(If “yes” is the answer to two or more of the above please have physician complete medical clearance form prior to exercise)

Health and Fitness goals? ____________________________________________________________________

What has stopped you from reaching your goals in the past? ______________________________________

How many days can you exercise? ____________________________________________________________

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Waiver, Release, and Assumption of Risk Form

I have volunteered to participate in a fitness program provided to me by Fit and Balanced inc., which may include, but may not be limited to, resistance training and aerobic or cardiovascular exercise. In consideration of the trainer’s agreement to instruct and train me, I do here now and forever release and discharge and hereby hold harmless Fit and Balanced and his respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from.

THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT BELONGING TO FIT AND BALANCED OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT; (3) AND/OR NEGLIGENT INSTRUCTION OR SUPERVISION.

I have been informed of, understand and I am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity.

I also have been informed of, understand and i am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death.

I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed. If I have chosen not to obtain a physician’s consent prior to beginning this fitness program with Fit and Balanced, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate.

Photo Release I hereby grant Fit and Balanced permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of Fit and Balanced and will not be returned. I hereby irrevocably authorize Fit and Balanced to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST FIT AND BALANCED FOR YOUR NEGLIGENCE.

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Print Name

______________________________________________

Please sign and date

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