Health History (read and complete): PLEASE ENTER IN THE FULL NAME AND PHONE NUMBER OF YOUR EMERGENCY CONTACT PERSON IN "COMMENTS BOX" TO THE LEFT! When were you born? Prior to 1955 1955-1959 1960-1964 1965-1969 1970-1974 1975-1979 1980-1984 1985-1989 1990-1994 1995-1999 2000-2004 Have you ever had any form of heart disease? Yes No Have you ever experienced shortness of breath or chest pains? Yes No How long has it been since your last full physical? Within last 12 months 1-2 years ago 2-4 years ago 4-7 years ago More than 7 years ago Check any and all of the following that pertain to you: High Blood Pressure Cigarette Smoking Diabetes Family History of Heart Disease Do you work out at least three times a week? Yes No Are you currently taking any medication? If so, explain in "Comments Box" in left column. Yes No Do you have any problems in the following areas? Knees Lower Back Neck/Shoulders Hip/Pelvis Other (please explain in "Comments Box" in left column) Is there any other reason you know of that you should not participate in exercise? Yes (explain in "Comments Box" in left column) No 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 CrossFit Legacy, which may include, but not necessarily be limited to, CrossFit Legacy Boot Camp, CrossFit Legacy Kids, Cross Fit Training, and/or training of any kind by any affiliate, subsidiary or partnership of CrossFit Legacy and/or Brian Yoak (hereinafter collectively referred toast CrossFit Legacy). CrossFit Legacy made me fully aware that the fitness programs/classes which CrossFit Legacy 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 arenot 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 CrossFit Legacy 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 CrossFit Legacy. CrossFit Legacy informed me that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. CrossFit Legacy 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 CrossFit 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 CrossFit Legacy, and with my full understanding of all of the above, I hereby waive, release, remise and discharge CrossFit Legacy 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 CrossFit Legacy 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 CrossFit Legacy 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 CrossFit Legacy. 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 CrossFit Legacy, 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 CrossFit Legacy. Yes Use of picture(s)/film/likeness: By checking "Yes" in the check box that immediately follows this verbiage, I agree to allow CrossFit Legacy, 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 CrossFit Legacy 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 complete the following: 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? In Peak Condition Above Average Fitness About Average Below Average Really Out of Shape What is your age range? Teenager 20 - 25 26 - 35 46 - 55 56+ What is your gender? Female Male