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ETHOS SPORTS & FITNESS

&

CROSSFIT COUNTRY LLC

571 South Econ Circle, Oviedo Fl, 32765

407.375.0038

 


Health Assessment and Waiver

INFORMED CONSENT/ASSUMPTION OF RISK

 

I, agree to participate in one or more physical fitness program(s)/class(es) sponsored by CrossFit Country, which may include, but not necessarily be limited to CrossFit Training, and/or training of any kind by any affiliate, subsidiary or partnership of CrossFit Country has made me fully aware that the fitness programs/classes which CrossFit Country 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, rhabdomyolysis, or injury or death due to a medical condition, whether known or unknown by me. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in Crossfit Country 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 result of participation in a fitness program designed by CrossFit Country. I have been informed that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. CrossFit Country 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 Country fitness programs.

 

Release:

 

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 Country, and with my full understanding of all of the above, I hereby waive, release, remise and discharge CrossFit Country 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 Country fitness programs/classes/bootcamps, 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 Country 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.

Use of picture(s)/film/likeness: I agree to allow CrossFit Country, its agents, officers, principals, employees and volunteers to take and use 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 Country of this in writing.

 

Among the potential risks of strenuous exercise is a rare but serious condition known as Rhabdomyolysis. Rhabdomyolysis is a medical disorder that harms the kidneys. The disease results from the toxicity of destroyed muscle cells. A pigment that contains Iron, called myoglobin that exists in skeletal muscle enters the bloodstream after the muscle suffers damage. The kidneys have difficulty filtering the myoglobin out of the bloodstream, because it blocks the structures within the kidney, which can result in serious kidney damage or kidney failure. Additionally, the dead skeletal muscle can cause large shifts in fluid from the bloodstream into the muscle, which reduces the relative fluid volume of the body and can lead to shock and reduced blood flow to the kidneys.

 

This condition has many causes, among them are:

Severe exertion such as marathon running or calisthenics

Ischemia or necrosis of the muscles (as may occur with arterial occlusion or other conditions)

Seizures

Use or overdose of drugs-especially cocaine, amphetamines, statins, heroin, or PCP

Trauma

Shaking chills

Heat intolerance and/or heatstroke

Alcoholism (with subsequent muscle tremors)

Low phosphate levels

 

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 signing this form I am waiving valuable legal rights.

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
How did you hear about CrossFit Country?
Please select how you heard about us

Explain Other (Optional)
Students
Are you currently a college student?

School name:
Current Fitness Level
What is your current fitness level?
Inactive - Very little to no exercise at all.
Moderately Active - Some exercise but nothing a regular basis. (1 to 2 times per week.)
Active - Currently exercising on a regular basis. (3 to 4 times per week.)
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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