Full Name

Email *

Phone *

Address *

City *

State *

Postal code *

Gender

What Is Your Current Activity Level? *

Sedentary - Not Working Out At All

Low - 1-2 Days per week of light exercise

Moderate - Exercising 3 Days per week

High - Exercising 4+ Days per week at a High Intensity

Has your doctor said to avoid physical activity? *

Emergency Contact Name *

Emergency Contact Phone Number *

Participant’s Health Warranty:

The participant warrants and represents that the Participant has no disability, impairment, or ailment preventing him/her from engaging in active or passive exercise, or that will be detrimental or adverse to such person’s health, safety, or physical condition if he/she does so engage or participate. The Participant acknowledges and agrees that: 1) Wreck Room CrossFit will rely on the foregoing warning; 2) Wreck Room CrossFit shall have no obligation to perform a fitness assessment or similar testing to determine the Participant’s physical condition; 3) if any fitness assessment or similar testing is performed by Wreck Room CrossFit, it is solely for the purpose of providing comparative data with which the Participant can track progress in a program and is not for diagnostic purposes; 4) Wreck Room CrossFit shall not be subject to any claim, demand, or injury whatsoever on account of the Wreck Room CrossFit evaluation or interpretation of such fitness assessment or similar testing. Each Participant should be aware of his/her medical history and should consult with a physician prior to engaging in exercise or continuing to exercise if a medical condition appears or appears to be developing. Wreck Room CrossFit will encourage Participants to perform their exercises to the best of their ability however; it is the ultimate responsibility of the Participant to determine their own performance level.

Waiver and Release of Liability

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in any physical training regimen. These risks include, but are not limited to: falls 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. Injury may also result simply from the fact of physical training itself. By its very nature, physical training seeks to have me push beyond my limits in order to produce a physical adaptation by my body. This requires feedback from me to my trainer regarding what is happening with my body. Excessive work can result (in rare cases) in exertional rhabdomyolysis. I should look for signs of excessive soreness, darkened urine, and pain in the kidney areas in the days following a particularly intense workout. While this type of injury is relatively rare, it can occur due to a number of factors, including (but not limited to) genetic predisposition or dehydration that may be beyond the control of my trainer. This Waiver and Release of Liability includes, without limitation, injuries which may occur as a result of first aid, emergency treatment or any other services which are negligently rendered or failed to be rendered by released parties, emergency personnel or Good Samaritans, or our negligently preventing a Good Samaritan from rendering first aid. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while training with Wreck Room CrossFit, either at 180 Penrod Ct. Suite D Glen Burnie MD 21061 or other locations.

Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities available at Wreck Room CrossFit, I, the undersigned hereby release CrossFit Inc. and 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 participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Health & Fitness Classes, Programs or Workshops. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the Exercise Classes, Health Programs or Workshops.

Agreement Competency: 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 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.

Indemnification: The participant recognizes that there is risk involved in the types of activities offered by CrossFit Inc. and Wreck Room CrossFit. Therefore the participant accepts financial responsibility for any injury that 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 any 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 CrossFit Inc. and 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 negligence or intentional act or omission while participating in activities offered by Wreck Room CrossFit.

Photo/Video Release: I hereby grant Wreck Room CrossFit permission to use my photograph/video image in any and all publications for CrossFit or Wreck Room CrossFit, including web site entries, without payment or any other consideration in perpetuity. I hereby authorize Wreck Room CrossFit to edit, alter, copy, exhibit, publish or distribute all photos and images. I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my photo appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph or video images.

Child/Kin Release: I understand that if I bring my children or other children with me to Wreck Room CrossFit , I am responsible for their safety and well being. I will not hold Wreck Room CrossFit or any of their representatives responsible if any child or children that are under my care and/or supervision in the gym or on the property, become injured at any time. I hereby hold harmless and release and forever discharge Wreck Room CrossFit from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on behalf of my estate which may have or may have by reason of this authorization.

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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