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TODAY'S DATE: April 24, 2024

 

I, the undersigned, hereby expressly and affirmatively state that I wish to participate in fitness assessments, activities, programs, andsports conditioning and in the use of exercise equipment at various sites including home, club or worksite that may be provided orrecommended by Keith A. Britton, Juggernaut Strength LLC, CrossFit Juggernaut, CrossFit, Worlds Best Boot Camp, coaches, trainers,affiliates, directors, officers, agents, employees, representatives, successors, and assigns (Facility). I realize that my participation inthese activities or in the use of equipment involves various risks of injury including but not limited to musculoskeletal, soft-tissue,neurological, rhabdomyolysis, and cardiovascular injury and even the possibility of death. I also recognize that there are many other risksof injury, including serious disabling injuries that may arise due to my participation in these activities or in the use of equipment and thoserisks, including remote ones, have been reviewed with me. I hereby expressly assume all of the delineat-ed risks of injury, all otherpossible risks of injury and even the risk of death which could occur by reason of my participation in any of the assessments, activities orprograms or in the use of equipment in any or all settings
IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL:


 

I have had an opportunity to ask questions regarding my participation in various activities and in the use of exercise equipment. Anyquestions I have asked have been answered to my complete satisfaction. I subjectively understand the risks of my participation in variousactivities or in the use of equipment and knowing and appreciating these risks, I voluntarily choose to participate, assuming all risks ofinjury and death, which may arise due to my participation
IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL:


I further acknowledge that my participation in the activities and use of equipment is completely voluntary and that it is my choice to participate and/or use equipment or not to participate as I see fit. IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL:


 

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In consideration of being allowed to participate in the activities, training, and programs provided by Keith A. Britton, Juggernaut StrengthLLC, CrossFit Juggernaut, CrossFit, Worlds Best Boot Camp, coaches, trainers, affiliates, directors, officers, agents, employees,representatives, successors, and assigns, and/or in the use of its facilities, equipment and machinery, I do hereby waive, release andforever discharge Keith A. Britton, Juggernaut Strength LLC, CrossFit Juggernaut, CrossFit, Worlds Best Boot Camp, coaches, trainers,affiliates, directors, officers, agents, employees, representa-tives, successors, and assigns (Facility), and all other from any and allresponsibility or liability for injuries or damages resulting from my participation in any activities at Facility or elsewhere. I do also releaseall of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself,
including those caused by the negligent act or omission of any of those mentioned or other acting on their behalf or in any way arising outof or connected with my participation in any of the contemplated activities or in the use of equipment and machinery through the Facilityor otherwise. I understand that this release is given in advance or any injury or damage to me and that it includes injury or damage to mecauseby the ordinary negligence of those released hereby but not from gross negligence, willful/wanton/intentional or criminal conduct.This agreement also serves as a release and assumption of risk for my heirs, executors and administrators and for all members of myfamily, including any minors.
IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL:


I understand and am aware that strength, flexibility, aerobic exercise including the use of equipment is a potentially hazardous activity. Sports conditioning and fitness coaching is an activity requiring considerable coordination, agility, and a high level of cardiovascular fitness. It involves vigorous activity for as long as an hour or more, many quick bursts of speed, and being alert to fast moving objects in a designated space. IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL:


 

I do further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness thatwould prevent my participation in any of the activities and programs provided through Facility or in use of equipment. I do hereby
acknowledge that I have been informed of the need or desirability for a physicians approval for my participation in exercise/fitness activityor in the use of exercise equipment. I also acknowledge that it has been recommended that I have a yearly physical examination andconsultation with my physician as to physical activities, exercise and as to the use of exercise equipment so that I might have recommendations concerning these physical activities and equipment use. I acknowledge that I have either had a physical examination and havebeen given my physicians permission to participate or that I have decided to participate in activity and/or use of equipment without theapproval of my physician and do hereby assume all responsibility for my participation and activities or in the utilization of equipmentwithout that approval.
IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL:


 

Photography/Video Release

Participants involved in any activities offered by Keith A. Britton, Juggernaut Strength LLC, CrossFit Juggernaut, CrossFit, Worlds BestBoot Camp, coaches, trainers, affiliates, directors, officers, agents, employees, representatives, successors, and assigns may bephotographed or videotaped. The undersigned hereby consents to the use of these photographs and/or videos without compensation, onthe CrossFit Juggernaut or World's Best Boot Camp website or in any editorial, promotional or advertising material produced and/orpublished by CrossFit Juggernaut or World's Best Boot Camp.
IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL:


 

IN WITNESS WHEREOF, the participant and the participants parent(s) have executed this Express Assumption of Risk/ProspectiveWaiver of Liability and Release Agreement this April 24, 2024, which shall be binding upon each of them andtheir respective heirs, executors, administrators and assigns. Each does hereby further agree to indemnify and hold Facility and all thoseindentified or name herein absolutely harmless in the event that anyone claiming any cause of action as a result of any injury and/ordeath to participant attempts at any time to institute any claim or suit against Facility/ Keith A. Britton, Juggernaut Strength LLC, CrossFitJuggernaut, CrossFit, Worlds Best Boot Camp, coaches, trainers, affiliates, directors, officers, agents, employees, representatives,successors, and assigns arising out of any of the activities or programs herein or in the use of any equipment.


INFORMED CONSENT AND RELEASE

 

I declare that I intend to use some or all of the activities, facilities, programs, and services offered by CrossFitJuggernaut, Juggernaut Strength LLC, CrossFit, Worlds Best Boot Camp, Keith A. Britton, its directors, officers, agents,employees, representatives, successors, and assigns. I understand that each person, (myself included), has a differentcapacity for participating in such activities, facilities, programs & services. I am aware that all activities, services, andprograms offered are educational, recreational, or self-directed in nature. I assume full responsibili-ty, during and after myparticipation, for my choices to use or apply, at my own risk, any portion of the information or instruction I receive. Iunderstand that part of the risk involved in undertaking any activity or program is relative to my own state of fitness orhealth (physical, mental, or emotional) and to the awareness, care and skill with which I conduct myself in that activity orprogram. I acknowledge that my choice to participate in any activity, service, andprograms of CrossFit Juggernaut,Juggernaut Strength LLC, CrossFit, Worlds Best Boot Camp, Keith A. Britton, its directors, officers, agents, employees,representatives, successors, and assigns brings with it my assumption of those risks or results stemming from this choiceand the fitness, health, care and skill that I possess and use.


I recognize that by participating in the activities, facilities, programs and services offered by CrossFit Juggernaut,Juggernaut Strength LLC, CrossFit, Worlds Best Bootcamp, Keith A. Britton, its directors, officers, agents, employees,representatives, successors, and assigns, I may experience potential risks such as transient light-headedness, fainting,abnormal blood pressure, chest discomfort, leg cramps, and nausea and that I assume willfully those discomfort, fatigue,or any other symptoms that I may suffer during and immediately after my participation. I under-stand that I may stop ordelay my participation in any activity or procedure if I so desire and that I may also be requested to stop and rest by asupervising employee who observes any symptoms of distress or abnormal response.I recognize that exercise is not without some risk to the musculoskeletal system (sprains, strains) and cardio respiratory system (dizziness, fainting, abnormal heartbeat, discomfort in breathing, abnormal blood pressure, in rare instancesheart attack or stroke) I hereby certify that I know of no medical problem (except those on the fitness profile questionnaire)that would increase my risk of illness or injury as a result of participation in a regular exercise program. I understand that the
completion of this form will not result in any type of diagnosis of disease and that it is not intended as a substitute forconsultation with my personal health care provider. I must consult my own personal health care provider for any evaluationof my health status. I hereby waive, discharge, absolve, hold harmless and forever release CrossFit Juggernaut,Juggernaut Strength LLC, CrossFit, Worlds Best Boot Camp, Keith A. Britton, its employees, officers, agents,representatives, executors, and all those associated from any and all liability arising out of any accident, injury, or losssustained by me as a result of activities at or in the presence of CrossFit Juggernaut, Juggernaut Strength LLC, CrossFit,Worlds Best Boot Camp, Keith A. Britton, its directors, officers, agents, employees, representatives, successors, andassigns, managed facilities, activities, programs and services.

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
First Participant's Signature*
Second Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
Third Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
Fourth Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
Fifth Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
Sixth Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
Seventh Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
Eighth Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
Ninth Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
Tenth Participant's Name

First Name*

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

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
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.
HEALTH HISTORY QUESTIONNAIRE

Please read the following questions and answer each one honestly by checking Yes or No. 

1. Have you ever been diagnosed with a heart condition?*
2. Have you ever had a stroke?*
3. Do you have epilepsy?*
4. Are you pregnant?*
5. Do you have diabetes?*
6. Have you ever been diagnosed with pulmonary disease including emphysema, chronic bronchitis, or asthma?*
7. Do you feel pain in your chest when you engage in physical activity?*
8. In the past month, have you had chest pain when you were NOT doing physical activity?*
9. Have you ever lost consciousness or have you ever lost control of your balance due to chronic dizziness?*

Have you ever experienced or been told you have any of the following?

10. Coronary angioplasty (CPTA) or cardiac surgery*
11. Rapid heart beats or palpitations*
12. Known heart murmur*
13. Anemia*
14. Phlebitis 1*
15. Heart attack/ myocardial infarction*
16. Metabolic disease (thyroid disorders, renal or liver disease)*
Are you currently being treated for a bone or joint problem, such as arthritis, that restricts your ability to exercise?*

If Yes, please explain:
Do you have high blood pressure as reported by a physician (greater than 140/90 mm/hg) or are you on blood pressure medication?*
Has anyone in your immediate family (parents/brothers/sisters) had a heart attack, stroke, or cardiovascular disease before age 55?*
Do you have high cholesterol as reported by your physician (greater than 200mg/dI) or are you on cholesterol medication?*
Do you smoke?*
Are you currently exercising LESS than one hour per week?*
Do you have an excessive accumulation of fat around the waist as indicated by your physician?*
Have you gone through premature menopause without estrogen replacement therapy?*
Are you a male over 45 years of age?*
Are you a female over 55 years of age?*

If you answered YES to (2) two or more questions above, you will need to obtain a medical clearance. Ask for the form "To be completed by personal health care provider" to your physician and have him/her complete the page. 

Are you currently taking any medication?*

If Yes, please specify: 


Name

Dosage

Purpose
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 Information

Emergency Contact


Name

Relationship:

Home Phone:

Business Phone:

E-Mail:
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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