Birthday Child’s Name *

Your First Child's Name *

Your First Child's Date of birth *

Your First Child's Gender *

Your Second Child's Name

Your Second Child's Date of Birth

Your Second Child's Gender

Parent/Guardian First Name *

Parent/Guardian Last Name *

Your Relation to Child(ren) *

Email *

Phone Number *

Address *

City *

State *

Zip code *

Emergency Contact Name *

Emergency Contact Phone Number *

Important Information About Your Child's Health

Wreck Room CrossFit services are not a substitute for professional medical advice or a medical examination. Prior to participating in any program, activity, or exercise you should seek the advice of your physician and other qualified health-care professionals. You understand that these exercises can be strenuous and should be done in moderation. There is an inherent risk in any exercise that, while providing some health benefits, can also cause unknown health issues. You understand that there are weights, balls, bars, mats, chairs, and many other items commonly associated with a gymnasium that can be left around by any person associated with Wreck Room CrossFit. It is every person’s responsibility to anticipate these items being left in places where they can cause injury. Application or reliance on the techniques, advice, ideas, and suggestions of any person associated with Wreck Room CrossFit are at the sole discretion and risk of the participant and his/her parent and guardian. You agree, by participating in any program associated with Wreck Room CrossFit, that Wreck Room CrossFit shall not be liable for any direct, indirect, special, consequential, or exemplary damages for any injury or harm to you or your child incurred in or around the property where exercise occurs. I willingly assume full responsibility for the risks that I am exposing my child to and accept full responsibility for any injury or death that may result from his/her participation in any activity or class while at Wreck Room CrossFit.

Waiver and Release of Liability

Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily allowing my child’s participation in the activities available at Wreck Room CrossFit, I hereby release Wreck Room CrossFit, their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my child’s participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. I, the undersigned acknowledge that my child has no physical impairments or illnesses that will endanger him/her or others.

IN CASE OF EMERGENCY: I also give full permission for any person connected to Wreck Room CrossFit 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. IMAGES: I authorize Wreck Room CrossFit to take pictures and movies of me and use them on their website and in other promotional and educational materials. I also understand that I may request their removal at anytime.

INDEMNIFICATION: I recognize that there is a risk involved in the types of activities offered by Wreck Room CrossFit I therefore accept financial responsibility for any injury that I or my child may cause either to myself or to others. I will reimburse them for such fees and costs. I agree to indemnify an hold harmless Wreck Room CrossFit, 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 my negligent or intentional act or omission while participating in activities offered by Wreck Room CrossFit.

ACCEPTANCE: I have read and understood the foregoing 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 me. I understand that by signing this form I am waiving valuable legal rights. By entering the information below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature. By signing below, I confirm that all personal information is correct and I have read and understood 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 waiving valuable legal rights.

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