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Agreement, Release and Waiver of Liability FITNESS by EXAMPLE LLC

DISCLAIMER:You should always consult with your Doctor before beginning any type of exercise or physical activity.

This form is an important legal document. It explains the risks you are assuming by beginning an exercise program. It is critical that you read and understand it completely. After you have done so, please print your name legibly and sign in the spaces provided at the bottom.

Waiver, Informed Consent, and Covenant Not to Sue

I have volunteered to participate in a program of physical exercise under the direction of Fitness by Example LLC, which will include, but may not be limited to, weight and/or resistance training. In consideration of Fitness by Examples agreement to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless Fitness by Example, LLC, and Indian Hills Middle School, their 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 therefrom. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) MY USE OF ALL AMENITIES AND EQUIPMENT IN THE Fitness by Example AND Indian Hills Middle School BOOT CAMP FACILITIES OR PREMISES AND MY PARTICIPATION IN ANY ACTIVITY, CLASS PROGRAM, PERSONAL TRAINING OR INSTRUCTION (2) EQUIPMENT THAT MAY MALFUNCTION OR BREAK (3) THEIR NEGLIGENT INSTRUCTION OR SUPERVISION (4) ANY SLIPING AND/OR FALLING DROPPING OF EQUIPMENT WHILE ON Fitness by Example AND Indian Hills Middle School BOOT CAMP PREMISES INCLUDING ADJACENT SIDEWALKS AND PARKING AREAS.

Assumption of Risk

To the best of my knowledge I am in good physical condition and have no disease, physical limitation, health concern or injury that would be aggravated or would be the cause of any injury sustained, before, during or as a result of my participating in activities related either directly and/or indirectly to Fitness by Example, LLC.

I recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart attack; and, in rare instances, death.

I understand that as a result of my participation in an exercise program, I could suffer an injury or physical disorder that could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I recognize that an examination by a physician should be obtained by all participants prior to involvement in any exercise program. If I have chosen not to obtain a physicians permission prior to beginning this exercise program with Fitness by Example, LLC, I hereby agree that I am doing so at my own risk.

In any event, I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate.

I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE 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 FITNESS BY EXAMPLE, LLC AND Indian Hills Middle School FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.

First Participant's Name

First Name*

Middle Name

Last Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle 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*
Has your doctor ever said you have heart trouble?

If yes, please describe the problem and state when it was diagnosed.
Do you frequently have pain in your heart or chest?
Do you often feel faint or have spells or severe dizziness?
Has a doctor ever told you that your blood pressure was too high?
Has your doctor ever told you that you have a bone or joint problem such as arthritis, that has been aggravated by exercise or might be made worse by exercise?
Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to do so?
Are you over age 65 and/or not accustomed to vigorous exercise?
Are you or have you ever been a diabetic?
Are you pregnant, or have you been pregnant within the last 3 months?
Have you had any surgery in the last 3 months?
Have you been hospitalized in the last 2 years?

If so, when and why?
Have you ever seen a chiropractor, acupuncturist, or other alternative medicine practitioner?

If so, when and why?
Please check the box if you have ever experienced any of the following symptoms:
Pain or discomfort in the chest
Unaccustomed shortness of breath
Dizziness
Labored or uncomfortable breathing, with or without pain
Swollen ankles
Heart palpitations
Heart murmur
Limping

If you checked any of the boxes above, please explain: "When first experienced & treatment used"
Do you have high blood pressure?

If yes, what is your current blood pressure without medication?
Are you taking any medication for hypertension?
Is you total serum cholesterol level over 240?
Do you smoke?

If so, when did you quit?
Do you have diabetes?
Do you have a family member who has had coronary or atherosclerotic disease before age 55?
Do you have pain or discomfort in your back?
Do you have pain or discomfort in your knee?

If so, right? or left?
Do you have pain or discomfort in your shoulder?

If so, right? or left?
Do you have pain or discomfort in your elbow?

If so, right? or left?
Do you have pain or discomfort in your wrists?

If so, right? or left?
Do you have pain or discomfort in your ankle?

If so, right? or left?
Have you ever torn ligaments or cartilage in your knee?

If so, when?
Did you have surgery on this knee?

If so, when?

Have you ever dislocated your shoulder?

If so, when?
Have you ever had shoulder surgery?

If so, which shoulder? When?
Have you ever had a neck injury, such as whiplash?

If so, when?
Have you ever been treated for a spinal disk injury?

If so, when?
Do you ever experience tingling or numbness in your elbows or hands?

What is the present state of you general health?

What regular physical activities do you do now?

How often?

For how long each session?
I certify that I understand the foregoing questions and my answers are true and complete, I also understand that this information is being provided as part of my initial consultation and may not be periodically updated.
I assume the risk for any changes in my medical condition that might affect my ability to exercise.
If you answered yes to one or more questions and you have not recently consulted with your doctor, do so before beginning an exercise program. Tell your doctor which questions you answered yes to and explain that you plan to undergo an exercise program that may include, but not be limited to, weight and/or resistance training. After medical evaluation, ask you doctor: 1. which activities may safely participated in, and 2. What specific restrictions, if any, should apply to your condition and which activities and/or exercises you should avoid.
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*

Middle 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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