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Name *
Name
Mobile Phone *
Mobile Phone
Date of Birth *
Date of Birth
On-Ramp? Personal Training? Drop in? Member update? Other?
Have you ever had any form of heart disease?
Do you have any current injuries?
Have you ever experienced shortness of breath or chest pains?
Do you have a family history of heart disease?
Do you have problems with your knees?
Do you have problems with your back?
Do you have any hip/pelvis problems?
Do you have high blood pressure?
Do you have any neck/shoulder problems?
Do you have diabetes?
Do you have any current injuries?
Do you have any allergies?
Are you currently taking any medication?
Are you a smoker?
Are you currently exercising?
Have you participated in strenuous exercise before?
Do you ever get dizzy?
Are there any exercises that you know you cannot do for medical reasons?
Is there any reason you know of that you should not participate in exercise?
WARNING … Safety first!!
Waiver and Release of Liability Generator Industries Pty Ltd (trading as “CrossFit Warrnambool”) 38-40 Albert Street Warrnambool Victoria 3280 Waiver and Release of Liability Generator Industries Pty Ltd (trading as “CrossFit Warrnambool”) 38-40 Albert Street Warrnambool Victoria 3280. In consideration of Generator Industries Pty Ltd allowing me to participate, I acknowledge, understand and I am aware that: I have voluntarily chosen to participate in training activities provided by a Generator Industries Pty Ltd, trading as “CrossFit Warrnambool”. I understand there are inherent risks in all aspects of physical training and I acknowledge that I have been informed of the possible strenuous nature of the training and the potential for undesirable physiological results including, but not limited to, abnormal blood pressure, muscle soreness, fainting, heart attack and/or death. I also acknowledge that I have been specifically warned about the medical condition “Rhabdomyolysis” and accordingly I have been advised to limit my effort in order to minimise the risks associated with this condition.
I understand that the training may involve weightlifting, gymnastic movements, strenuous body weight exercises and other high exertion activities and that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my trainer. I give Generator Industries Pty Ltd and the staff of the facilities I train in permission to seek emergency medical services for me should I become injured or ill with the understanding that I am responsible for any expenses incurred.
I agree to WAIVE ANY AND ALL CLAIMS that I have or may have in the future against Generator Industries Pty Ltd, and its directors, officers, employees, agents, volunteers and independent contractors (all of whom are hereinafter collectively referred to as “the Releasees”). I agree to RELEASE THE RELEASEES from any and all liability for any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer as a result of my participation in the programs, activities and services provided by Generator Industries Pty Ltd, due to any cause whatsoever including negligence, breach of contract, or breach of any statutory or other duty of care. I agree to HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any damage to the property of, or personal injury to, any third party, resulting from my participation in any program, activity or service provided by the releasees.
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 Generator Industries Pty Ltd 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 Generator Industries Pty Ltd, its agents, officers, principals, employees and volunteers to 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 Generator Industries Pty Ltd of this in writing.
I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS “INFORMED CONSENT FORM” I AM WAIVING CERTAIN LEGAL RIGHTS (INCLUDING THE RIGHT TO SUE) WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTOR, ADMINISTERS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES. ANY QUESTIONS I HAD WERE ANSWERED TO MY FULL SATISFACTION.