Fitness with Kimberly PAR-Q Form and Waiver
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Email *
Name *
Date *
Email *
Phone Number *
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? *
Do you frequently have pains in your chest when you perform physical activity? *
Have you had chest pain when you were not doing physical activity? *
Do you lose your balance due to dizziness or do you ever lose consciousness? *
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? *
Are you pregnant now or have given birth within the last 6 months? *
At this present time, do you have any health conditions or injuries that would affect or limit your training? *
Have you had a recent surgery? *
If you answered “NO” honestly to ALL PAR-Q questions you can be reasonably sure that you can become more physically active and take part in physical training. If you are or may be pregnant--talk with your doctor before you start becoming more active. If you answered YES to ANY of the above questions, you must tell our fitness professionals. If you have marked YES to any of the above, please elaborate below:
Do you take any medications, either prescription or non-prescription, on a regular basis? *
If Yes, What is the medication and its use ?
How does this medication affect your ability to exercise or achieve your fitness goals?
Please check any of the following injuries you have had and specify which bone, muscle, joint, etc., and the year the injury occurred:
Are you currently being treated for any of the above injuries? Please specify the type of treatment.
*If you have answered yes to any of the above, a doctors release may be required before you can participate in classes or with personal training.
Fitness with Kimberly Liability Waiver:
Fitness with Kimberly RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT I understand the nature of the Fitness with Kimberly activities and am qualified to participate in such activities. If at any time I believe conditions to be unsafe, I will immediately discontinue further participation and notify the instructor of Fitness with Kimberly. I hereby represent and warrant that I am at least 18 years of age. I fully understand that: (a)Fitness with Kimberly activities involve risks and dangers including SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH (“Risks”); (b) these Risks may be caused by my own action or inaction, the action or inaction of others (including other activity participants), the condition of in which the activity takes place, or THE NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be other risks and social and economic losses either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES incurred as a result of my participation in the activity. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS (a) Fitness with Kimberly, (b) other participants, (c) any sponsors or advertisers, and (d) the instructor who is leading classes and/or sessions where the activities take place (each considered one of the “Releasees” herein) from and against all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of one or more of the “Releasees” or otherwise, including negligent rescue operations and further agree that if, despite this release, if I, or anyone on my behalf, make a claim against any of the Releasees named above, I will indemnify, save and hold harmless each of the releases from any litigation expenses, attorney fees, loss liability, damage or costs that may occur as the result of any such claim. I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT DESCRIPTION OF THE EXERCISE PROGRAM AND POTENTIAL RISKS: I understand and do hereby consent to participate in a fitness training program that will include stretching, cardiovascular and strength training exercises. I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to occasional minor injuries (e.g. pulled muscles, muscle soreness, muscule-skeletal strains and sprains, bruises) to infrequent serious injury (e.g. heart attack, stroke or other cardiovascular accidents, muscle tears) to the very rare catastrophic incident (e.g. death, paralysis). I acknowledge that regardless of the care taken, Fitness with Kimberly cannot guarantee my personal safety. PARTICIPANT RESPONSIBILITIES: I understand it is my responsibility to 1) fully disclose any health issues (including diabetes, heart problems, seizures, or asthma) or medications that are relevant to participation in a strenuous exercise program; 2) inform the instructor or trainer if there are any changes to my health, including injuries and sickness; 3) inform the instructor or trainer if there are activities with which I do not feel comfortable; 4) cease exercise and report promptly any unusual feelings (e.g., chest or other discomfort, nausea, difficulty breathing, injury) during the exercise program; and 5) clear my participation with my physician. PARTICIPANT ACKNOWLEDGEMENTS: In agreeing to this exercise program, I, the participant 1) acknowledge that my self-participation is completely voluntary; 2) understand the potential physical risks involved in the exercise program, and believe that the potential benefits outweigh those risks; 3) give consent to certain physical touching that may be necessary to ensure proper technique and body alignment; 4) understand that the achievement of health or fitness goals cannot be guaranteed; 5) have been able to ask questions regarding any concerns I might have, and have had all questions answered to my satisfaction; 6) am in good physical condition, have no impairment which might prevent my participation in such activities, and have been advised to consult a physician prior to beginning this program; 7) have been advised to cease exercise immediately if I experience unusual discomfort and feel the need to stop. REVOCATION OF RIGHTS: Fitness with Kimberly reserves the right to suspend, revoke or cancel your membership or right to participate in any activity at any time and for any reason. If your membership or rights to participate in classes or sessions are terminated, Fitness with Kimberly will refund an amount equal sums paid for the current period prorated for any partial period or unused classes less expenses incurred by Fitness with Kimberly in connection with such termination or as a result of any breach by the you of this Agreement or any policy or rules of Fitness with Kimberly or the portion of the total price of this agreement representing the services used or completed, and provided further, that Seller may demand the reasonable cost of goods and services which the Buyer/Member has consumed or wishes to obtain after cancellation. I HAVE READ AND UNDERSTAND THE ABOVE AGREEMENT. I HAVE BEEN MADE FULLY AWARE OF AND UNDERSTAND THE POTENTIAL RISKS INVOLVED WITH THE PHYSICAL FITNESS AND OTHER ACTIVITIES OFFERED BY FITNESS WITH KIMBERLY. I HEREBY CONSENT TO THOSE RISKS AND AM FREELY AND VOLUNTARILY SIGNING THIS AGREEMENT AND PARTICIPATING IN THESE ACTIVITIES. ACKNOWLEDGED AND AGREED:
Date: *
Please enter your full name (this will constitute your electronic signature for agreeing to all terms above). *
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