Name
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First Name
Last Name
DOB
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Phone
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(###)
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Email
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
Emergency Contact Phone Number
(###)
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Do you Smoke?
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Do you drink alcohol?
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Do you take prescription medication?
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Do you play sports?
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Do you have back pain, knee pain or shoulder pain?
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Any previous injuries or surgeries?
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Do you have high BP, asthma, diabetes or a heart condition?
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Any other health conditions that are not listed?
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How many times a week do you exercise?
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Photography/ Video Release: Participants involved in any activities offered by Chaos Strength and Conditioning may be photographed or videotaped during training. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Chaos Strength and Conditioning website or in any editorial, promotional, or advertising material produced and/or published by Chaos Strength and Chaos.
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Waiver: Express assumption of risk: 1, 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 severe 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; strains and sprains. I am aware that any of these above-mentioned risks may result in severe injury or death to myself and or my partner(s). I willingly assume full responsibility for the chances that I am exposing myself to and accept full responsibility for any injury or death resulting from participation in any activity or class while at, or under the direction of Chaos Strength and Conditioning. I acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others.
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Release: 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 offered by Chaos Strength and Conditioning, I, the undersigned hereby release Chaos Strength and Conditioning 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 Chaos Strength and Conditioning 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 wellbeing of the child. Indemnification: The participant recognizes that there is risk involved in the types of activities offered by Chaos Strength and Conditioning. 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 Chaos Strength and Conditioning, 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 Chaos Strength and Conditioning, at the main building or abroad. This includes but is not limited to parks, recreational areas, playgrounds, areas adjacent to the main building, and/or any area selected for training by Chaos Strength and Conditioning.
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I have read and understood the foregoing assumption of risk, and release of liability and I understand that 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.
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(signature of parent/guardian if participant is under the age of 18)
