Waiver – The Gauntlet

WAIVER

PARTICIPANT / LEGAL GUARDIAN INFORMATION

Emergency Contact Phone Number

Name

Date of Birth

Cell Phone

Address

Emergency Contact Name

Emergency Contact Phone Number

Have you ever had any form of heart disease?

Yes No

Have you ever experienced shortness of breath or chest pains?

Yes No

High Blood Pressure?

Yes No

Cigarette Smoking?

Yes No

Diabetes?

Yes No

Family History of Heart Disease?

Yes No

Do you work out at least three times per week?

Yes No

Date of last full physical:

Are you currently taking any medication?

Is there any reason you know of that should prevent you from participating in exercise?

INFORMED CONSENT/ASSUMPTION OF RISK

I agree to participate in one or more physical fitness program(s)/class(es) sponsored by Gauntlet Fitness, LLC. Gauntlet Fitness made me fully aware that the fitness programs/classes which Gauntlet Fitness offers and in which I desire to participate are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. I, the undersigned recognize and understand that the programs/classes are not without varying degrees of risk which may include, but are not limited to the following: Injury to the musculoskeletal and/or cardio respiratory systems 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 a 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).

I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in Gauntlet 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 that would increase my risk of illness and injury as a result of participation in a fitness program designed by Gauntlet Fitness. Gauntlet Fitness informed me that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. Gauntlet Fitness informed me that these changes could include abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and in very rare instances, heart attack or even death, and I fully understand the same. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in Gauntlet Fitness programs/classes.

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 Gauntlet Fitness, and with my full understanding of all of the above, I hereby waive, release, remise and discharge Gauntlet 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 Gauntlet Fitness programs/classes, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties.

IMDEMNIFICATION

I recognize that there is risk involved in the types of activities offered by Gauntlet 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 Gauntlet 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 my negligent or intentional act or omission while participating in activities offered by Gauntlet Fitness.

USE OF PICTURE(S)/FILM/LIKENESS

I agree to allow Gauntlet Fitness, its agents, officers, principals, employees and volunteers the a 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 Gauntlet Fitness of this in writing.

USE OF PICTURE(S)/FILM/LIKENESS

I recognize and fully accept that open gym and parent/ninja time is a privilege and a time for all of us listed to play together at our own risk. I accept that coaches and/or supervision may not be provided to me nor my family during this time. I willingly assume full responsibility for any and all risks that I am exposing myself and my family to as a result of my participation.

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 waiving valuable legal rights.

ELECTRONIC SIGNATURE

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

If I am signing on behalf of a minor child, I also give full permission for any person connected with Gauntlet 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.

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.

PARTICIPANT / LEGAL GUARDIAN INFORMATION

Printable Waiver (PDF)

GAUNTLET FITNESS