WAIVER






Your Name (required):
Address:
City:
State:
Zip:


Email (required):
Contact Phone:
Emergency Contact Name:
Emergency Contact Phone:

Pledge Fitness

Recommends that you clear your participation in any exercise program with your physician.


Have you ever had heart disease? YESNO
Date of last physical:


Do you have or do any of the following pertain to your health? If Yes please explain.
Hepatitis C? YESNO Explain:
Liver Problems? YESNO Explain:
Kidney Problems? YESNO Explain:
High Blood Pressure? YESNO Levels:
Cigarette Smoking? YESNO
Diabetes? YESNO Type:
Family History of Heart Disease? YESNO Who/Age:
Do you work out at least three times per week? YESNO
Are you currently taking any medication? YESNO Explain:


Do you have any problems in the following areas?
Knees? YESNO Explain:
Lower Back? YESNO Explain:
Neck/Shoulders? YESNO Explain:
Hip/Pelvis? YESNO Explain:
Is there any reason you know of that you should not participate in exercise? YESNO Explain:
Any other Medical Condition/Disease(s) NOT Lister Above? YESNO Explain:


INFORMED CONSENT/ASSUMPTION OF RISK
I, , agree to participate in one or more physical fitness program(s)/class(es) sponsored by Pledge Fitness, which may include, but not necessarily be limited to, Pledge Fitness Boot Camp, Cross Training, and/or training of any kind by any affiliate, subsidiary or partnership of Pledge Fitness. Pledge Fitness has made me fully aware of the fitness program/classes, witch Pledge Fitness offers and in which I desire to participate are of a nature and kind that are extremely without varying degrees of risk, which may include, but not limited to the following:
Injury to the musculoskeletal and/or cardio respiratory system 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, or injury or death due to 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).
Initials:
I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in Pledge Fitness 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 other that those listed and described above, that would increase my risk of illness and injury as a result of participation in a fitness program designed by Pledge Fitness. Pledge Fitness informed me that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. Pledge Fitness informed me that these changes could include abnormal blood pressure, fainting, disorder of heat rhythm, stroke, and in very rare instances, heart attack or even death, and I fully understand of the above information, I agree to assume any and all risks associated with my participation in Pledge Fitness fitness programs/classes.
Initials:


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 Pledge Fitness, and with my full understanding of all of the above, I hereby waive, release, remise and discharge Pledge Fitness 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 Pledge Fitness fitness program/classes, including those allegedly attributed to the negligent acts or omissions of myself or other members.
This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, and/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 Pledge Fitness 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.
Initials:
Identification: I recognize that there is risk involved in the types of activities offered by Pledge Fitness. Therefore I accept financial responsibility for any injury that I or the participant may cause either to him/herself or to any other participant due to his/her negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless Pledge Fitness, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from client’s negligent or intentional act or omission while participating in activities offered by Pledge Fitness.
Initials:
Use of picture(s)/film/likeness: I agree to allow Pledge Fitness, its agents, officers, principals, employees and volunteers to photograph, 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 Pledge Fitness of this in writing.
Initials:
Arbitration. All claims and disputes arising under or related to this Agreement are to be settled by binding arbitration in the state of California or another location mutually agreeable to the parties. An award of arbitration may be confirmed in a court or competent jurisdiction.
Initials:


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 waving valuable legal rights.
Participant’s Name: Date:

Please note a copy of this legal electronic document will be emailed to you for your records.

Property of Pledge Fitness. All rights reserved

If you prefer a printed copy to sign please download the PDF version of the Health Assessment Waiver and Goals and bring the signed copy with you to our facility. 

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