NW Virtual StrongBodies Registration
Tuesday, January 16 to Thursday March 28, 2024 ; Tuesdays and Thursdays; 9:00 AM-10:15 AM
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First Name *
Last Name *
County of participation? *
Phone Number *
Street Address
City
State
Zip Code
Email Address *
Demographics: age in years *
Demographics: Gender *
Demographics: Race (Check ALL that apply) *
Required
Demographics: Ethnicity *
Programs that you and your family participate in (check all that apply):                                                                           (Note: This information is NOT shared and is only used to identify what funding UW-Extension uses for programming.) *
Required
In Case of Emergency, please call:  Include Name, Relationship, phone number. (ie Angela, Sister, 608-000-0000)
Physical Activity Safety: Please mark answers honestly to the following questions.   *
Required
Physical Activity Safety: Please list any medical concerns you would like your Strong Bodies instructor to know about (heart concerns, problems or pains with joints, etc.):
Physical Activity Safety: I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction. If you answered "YES" to one or more questions:If you marked ‘Yes’ to any of the above statements, you should seek further information from your medical professional before becoming more physically active or engaging in a fitness appraisal. If you answered NO to all of the questions above, you are cleared for physical activityStart becoming much more physically active. Begin slowly and build up gradually. This is the safest and easiest way to go.Delay becoming much more active if:You are not feeling well because of a temporary illness such as a cold or a fever. Wait until you feel better.You are or may be pregnant. Talk to your doctor before you start becoming more active.If your health changes so that you would answer YES to any of the above question tell your fitness or health professional. Ask whether you should change your physical activity. *
Assumption of Risks: StrongPeople National ProgramI understand that physical activity related to the StrongBodies Program, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Some of these involve strenuous exertions of strength using various muscle groups, some involve quick movement involving speed and change of direction, and others involve sustained physical activity, which places stress on the cardiovascular system. The specific risks vary from one activity to another, but in each activity the risks range from: 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as fractures, internal injuries, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death. I understand that the University has advised me to seek the advice of my physician before participating in this activity. I understand that I have been advised to have health and accident insurance in effect and that no such coverage is provided for me by the University or the State of Wisconsin. I know, understand, and appreciate the risks that are inherent in the above-listed programs and activities. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.Participant Waiver and Release of Liability (this “Release”) I, the undersigned, for myself individually, for my legal representatives, heirs, executors, successors, and assigns, and  for any minor under my supervision or control, in consideration of (a) being permitted to participate in any way in any activity,  event, or program offered, conducted, hosted, or sponsored by the StrongWomen Program, also known as the StrongPeople  Program (“StrongWomen/StrongPeople”), (b) being permitted to enter upon any real property owned, leased, or licensed by  StrongWomen/StrongPeople (the “Premises”) for any reason whatsoever, and/or (c) being permitted to use or take advantage  of any service, amenity, facility, or equipment provided by StrongWomen/StrongPeople or located on or about the Premises at  any time on, before, or after the date of this Release (collectively, the “Activities”), hereby represent, warrant, and agree as  follows: 1. Nature of Activities. I fully understand the nature of the Activities and that this program is only for adults. I possess the degree of skill, knowledge, and physical conditioning necessary to participate in the Activities safely. My  participation in the Activities is purely voluntary. I will participate in the Activities in a safe manner and exercise due care  while participating so as to neither endanger myself nor others. If, at any time, I believe that I am no longer fit to participate  in the Activities safely or that the conditions related to the Activities are unsafe, I will immediately discontinue further  participation in the Activities and bring any such unsafe conditions to the program leader’s attention.  2. Risks, Hazards, & Dangers. I fully understand that participating in the Activities involves inherent and incidental risks, hazards, and dangers, including, without limitation: (a) serious bodily injury to people (including, without  limitation, permanent disability, illness, paralysis, and death), (b) damage to or loss of personal property (including, without  limitation, loss of use or theft thereof), (c) those resulting from, arising out of, or related to rugged terrain, open or ice covered  water of any size or depth, dangerous or defective equipment and facilities, people handling and discharging firearms and  ammunition, vehicular traffic, all-terrain vehicles (e.g., ATVs and QUADs), dogs, natural wildlife, insects, weather conditions  and temperature, lack of hydration, physical condition of people, and actions of people, and (d) other risks, hazards, and  dangers and social and economic losses that could result or arise from participating in the Activities, whether known or  unknown or not readily foreseeable at this time) (collectively, the “Risks, Hazards, and Dangers”). The Risks, Hazards, and  Dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activities, the  conditions in which the Activities take place, the negligence of the Released Parties (as defined below), or otherwise. No  amount of supervision or care can eliminate the possible Risks, Hazards, and Dangers involved. StrongWomen/StrongPeople assumes no responsibility for any personal property that I bring or leave behind on or about the Premises. 3. Assumption of Risk. I hereby irrevocably, unconditionally, and voluntarily acknowledge, accept, and assume (a) all of the Risks, Hazards, and Dangers and (b) all of the responsibility for any and all Losses (as defined below) that  I incur or any minor under my supervision or control incurs resulting from, arising out of, or related to the Activities (including,  without limitation, my traveling to and from the Activities), whether such Losses were caused in whole or in part by the  negligence of the Released Parties (as defined below) or otherwise, excepting any Losses solely caused by the willful  misconduct of the Released Parties.  3.1 For purposes of this Release, “Losses” means, individually and collectively, any and all losses,  damages, injuries, penalties, expenses, costs, court costs, professional fees (including, without limitation, attorneys’ fees and  disbursements), interest, disbursements, judgments, liens, and liabilities of any kind or nature whatsoever (including, without  limitation, claims for the injury to or the death of any person or the damage to any property (including, without limitation, loss  of use or theft thereof).  4. Waiver and Release. I hereby irrevocably, unconditionally, and voluntarily release, discharge, and covenant not to sue the Released Parties from or with respect to any and all Claims that I, my legal representatives, heirs, executors,  successors, and assigns, and/or any minor under my supervision or control ever had, now have, or may hereafter have against  the Released Parties resulting from, arising out of, or related to the Activities (including, without limitation, my traveling to  and from the Activities), whether such Claims were caused in whole or in part by the negligence of the Released Parties (as  defined below) or otherwise, excepting any Claims solely caused by the willful misconduct of the Released Parties.4.1 For purposes of this Release, “Claims” means, individually and collectively, any and all claims,  actions, causes of action, suits, complaints, grievances, controversies, debts, dues, sums of money, accounts, reckonings, bonds,  bills, specialties, covenants, contracts, agreements, promises, variances, trespasses, judgments, liens, extents, executions,  decrees, claims (including, without limitation, claims for medical expenses), rights, demands, losses, damages, injuries,  professional fees (including, without limitation, attorneys’ fees and disbursements), costs, court costs, expenses, disbursements,  obligations, and liabilities of any kind or nature whatsoever (including, without limitation, claims for the injury to or the death  of any person or the damage to any property (including, without limitation, loss of use or theft thereof), whether at law,  admiralty, or in equity, whether known or unknown, contingent or absolute, suspected or unsuspected, disclosed or undisclosed,  hidden or concealed, or due or to become due, whether arising under contract, breach of warranty, tort, negligence, strict  liability, enterprise liability, product liability, any other theory of liability, or otherwise, and whether or not the party has been  advised of the possibility of such damages or such damages are otherwise foreseeable. 4.2 For purposes of this Release, “Released Parties” means, individually and collectively, (a)  StrongWomen/StrongPeople, (b) StrongWomen/StrongPeople’s program leaders, officers, directors, managers, members,  shareholders, employees, independent contractors, volunteers, agents, insurance providers, representatives, successors, and  assigns, and (c) the owners and lessees of the Premises. 5. Indemnification. To the fullest extent permitted by law, except to the extent attributable to the willful misconduct of the Released Parties, I will, at my sole expense, indemnify, defend, and hold harmless the Released Parties from  and against any and all Losses resulting from, arising out of, or related to: (a) any breach of or any inaccurate, false, or  fraudulent representation or warranty made by me in this Release; (b) any breach or default in the performance of any covenant  or agreement made by me in this Release; (c) my participation or the participation of any minor under my supervision or control  in the Activities; or (d) any willful misconduct, negligence, or fraudulent or unlawful acts or omissions of me or any minor  under my supervision or control. *
Optional: Media Release I understand while participating in any Activities, I may be photographed, filmed, or recorded. I hereby grant to StrongWomen/StrongPeople and its designees the irrevocable and unrestricted right to  use and publish in any manner or medium my name, my likeness, photographs and video of me (or in which I may be included),  and sound recordings of my voice, in whole or in part, solely for marketing, advertising, and promotional purposes and to alter  the same without restriction. *
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