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Embed code for: Team Grit Waiver Form 2016
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Please print and complete. Be sure to bring this to the competition! Team Grit Staff will have some on hand for you to complete if you are unable to print. See you at the Grit!
CrossFit Oyster Point
Tidewater Strength and Fitness, LLC Waiver Form
Home Address (Street)_______________________________(City)____________(State)____________
(Zip)________Phone (Home)_____________________(Work)________________________Ext______(Cell Phone #)________________DOB____/____/____ Weight_________Sex: M / F____
Private Physician___________________________ Phone_____________________________________
Your Work / Company____________________ __ I am currently a member at____________________
I heard about Team Grit/ CrossFitOP from__________________________________________________
I am enrolling in: ___ CrossFit Essentials (required for new CrossFitter's) ___ Clinic
___ CrossFitOP Classes ___ Team Grit Competition
___ Private Sessions ___ FREE first visit Drop In
SECTION I: RISK ASSESSMENT
Have you ever had any form of heart disease? YES NO
Have you ever experienced shortness of breath or chest pain? YES NO
Date of last full physical ____/_____/_____
Do you have or do any of the following pertain? Do you have any problems in the following areas?
Please explain to the best of your ability. Please explain to the best of your ability.
High Blood Pressure YES NO Levels:____________ Knees YES NO Explain:_______________
High Cholesterol Level YES NO Levels:____________ Low Back YES NO Explain:_______________
Cigarette Smoking YES NO How many per day?__ Neck/Shoulders YES NO Explain:_______________
Smoked in Past YES NO How long?_________ Hips/Pelvis YES NO Explain:_______________
Diabetes YES NO Insulin dependent?___ Flexibility YES NO Explain:_______________
Family history of heart disease YES NO Who/Age?__________ Any other YES NO Explain:_______________
Abnormal resting EKG YES NO Explain:____________
Are you active YES NO
Activity or Exercise / Times per week / Minutes per session:____________________________________________________
Are you currently taking any medication? YES NO Explain:________________________________________________
SECTION II: AGREEMENT
I, __________________________,(FULL NAME) agree to participate in Tidewater Strength and Fitness, LLC with a certified Instructor. I recognize that exercise is not without varying degrees of risk to musculoskeletal and/or cardio-respiratory systems. I hereby 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 Tidewater Strength and Fitness, LLC. I understand and have been informed that there exists the possibility of adverse changes during the exercise program. I have been informed that these changes could include abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and very rare instances of heart attack or even death. I agree to waive, release, remise and discharge Tidewater Strength and Fitness, LLC and its agents, officers, principals and employees of any and all claims, demands, actions or damages of any kind resulting from participation in Tidewater Strength and Fitness, LLC classes or individual training sessions. The undersigned hereby releases Tidewater Strength and Fitness, LLC as well as waives any and all claims and understands and assumes any and all risk with participation in Tidewater Strength and Fitness, LLC. ____________(Initial Here)
Participant Signature (sign & print name) Month, day, and year Instructor (sign & print name)
Parent or Guardian Signature (If Participant is under the age of 21)
SECTION III: Photography release
I grant to Tidewater Strength and Fitness, LLC, its representatives and employees the right to take photographs (still and video) of me and my property in connection with Fitness training. I authorize Tidewater Strength and Fitness, LLC, to use and publish the same in print and/or electronically. I agree that Tidewater Strength and Fitness, LLC may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above:
Signature ________________________Printed Name______________________Date________________
ur Work / Company____________________ __ I am currently a member at____________________
SECTION III: Photography