Physical Activity Readiness Questionnaire
Email address *
Date *
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Participant (last name) *
Your answer
Participant (first name) *
Your answer
Date of Birth *
MM
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DD
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YYYY
Phone Number (Participant) *
Your answer
Email Address (Participant) *
Your answer
Parent/Guardian (last name) *
Your answer
Parent/Guardian (first name) *
Your answer
Phone Number (Parent/Guardian) *
Your answer
Email Address (Parent/Guardian) *
Your answer
Address *
Your answer
Fitness Goals (check all that apply) *
Required
Medical History
Do you have a heart condition that you are aware? *
Are there any limitations to your heart condition? *
Do you have any other major illness that we should be made aware of? *
Please explain illness
Your answer
Do you smoke? *
Do you drink alcohol *
Are you on any current medications?
Please list any type of medications you are currently taking?
Your answer
Please list any type of supplements and or vitamins that you are currently taking?
Your answer
Exercise History
Frequency of weekly exercise
Nutritional Habits *
Required
Waiver & Release
In consideration of my participation in and physical training with Clarke Athletics, LLC, and Cosmo Clarke individually (collectively, “Clarke”) and any and all activities related thereto (“Activities”), I, the Participant, or the Participant’s Parent or Guardian, all as defined above, acknowledge and agree that:
1. The risk of injury from the Activities or use of any training or other equipment provided by Clarke or by or at any location or facility at which Clarke conducts its training (“Facility”) is significant, including 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. 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 of the Activities. I acknowledge that I have no physical impairments or illnesses that will endanger me or others;
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN OF PARTICIPATION IN THE ACTIVITIES AND USE OF THE EQUIPMENT OR TRAINING ITEMS (“EQUIPMENT”) AT THE FACILITY AND USE OF THE FACILITY, REGARDLESS OF WHETHER PARTICIPANT OR CLARKE SELECTS THAT EQUIPMENT OR FACILITY, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERS, AND I ASSUME FULL RESPONSIBILITY FOR MY PARTICIPATION;
3. I will comply with the stated and customary terms and conditions for participation in the Activities at the Facility or use of the Equipment. If, however, I observe any unusual significant hazard during my presence or participation, I will remove themselves from participation and bring such to the attention of the nearest official immediately;
4. I, ON MY OWN BEHALF AND ON BEHALF OF MY HEIRS, ASSIGNS, PERSONAL REPRESENTATIVES AND NEXT OF KIN, HEREBY RELEASE INDEMNIFY, AND HOLD HARMLESS CLARKE, THE FACILITY, AND THEIR OFFICERS, MEMBERS, OWNERS, OFFICIALS, AGENTS AND/OR EMPLOYEES, OTHER PARTICIPANTS, SPONSORING AGENCIES, SPONSORS, ADVERTISERS, AND IF APPLICABLE, OWNERS AND LESSORS OF THE FACILITY (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE TO PERSON OR PROPERTY, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, TO THE FULLEST EXTENT PERMITTED BY LAW RELATING TO THE ACTIVITIES, THE EQUIPMENT, OR THE FACILITY, INCLUDING ANY CLAIMS AGAINST THE RELEASEES BY THIRD PARTIES OR BY PARTICIPANT(S) AGAINST THE RELEASEES, AND INCLUDING ANY ATTORNEYS’ FEES ARISING FROM THOSE CLAIMS;
5. 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.
6. I give full permission for any person connected with Clarke or the Facility to administer first aid deemed necessary to me, and in case of serious illness or injury, I give permission to call for medical and or surgical care for me and to transport me to a medical facility if deemed necessary for my well-being. If I am signing on behalf of a minor child, I also give full permission for any person connected with Clarke or the Facility 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 child’s well-being of the child;
7. Any claim, cause of action, or request for monies or damages from Releasees must be commenced within one (1) year from the date on which any alleged claim first arose;
8. I expressly authorize Clarke and/or the Facility to take photographs and/or videotape of me or my minor child, and use them or their likenesses for any advertising, promotion, training, or product efforts by any method or device. Clarke owns all rights in said videotape and/or photographs.
9. I HAVE READ THIS WAIVER AND RELEASE, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THE RESPECTIVE PARTICIPANT SHEET, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT, as evidenced by my signature set forth above.
Initials (Parent/Guardian if Participant is under 18) *
Your answer
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