Participant Profile & Release Form
Agreement of Release and Waiver of Liability
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Physical Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
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Month
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Day
Year
Date
Emergency Contact Name
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First Name
Last Name
Emergency Number
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Area Code
Phone Number
How did you hear about us?
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
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Yes
No
Do you feel pain in your chest when you do physical activity?
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Yes
No
In the past month, have you had chest pain when you were NOT doing physical activity?
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Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
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Yes
No
Do you have a bone or joint problem (for example, neck pain, back pain, knee pain) that could be made worse from physical exercise?
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Yes
No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?
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Yes
No
Do you know of any other reason why you should not do physical activity?
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Yes
No
Initial below: If you answered yes to one or more of the above questions, you agree to obtain your doctor's approval before your session(s). In addition, if your circumstances change and you can answer yes to one or more of the above questions at any time in the future, you agree to obtain your doctor's approval before continuing your sessions.
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I agree
Has a doctor ever diagnosed you with a heart condition or a chronic disease?
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yes
no
If you answered yes to the above question, please explain:
Describe any previously diagnosed heart condition or chronic disease.
Do you currently have any pain or injuries?
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yes
no
If you answered yes to the above question, please explain:
Describe any pain or injuries.
Are you currently taking any medication that could affect your physical activity?
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yes
no
If you answered yes to the above question, please explain:
Describe any current medication that could affect your physical activity.
Initial Below: By signing this document, I acknowledge that I am participating in exercise sessions offered by Samantha Zilvitis, in person and/or online, live and/or recorded, either privately or in a group setting, during which I will receive information and instruction about health and fitness. I recognize that fitness programs require physical exertion which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.
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I agree
Initial Below: I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the exercise sessions. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the exercise sessions.
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I agree
Initial below. In consideration of being permitted to participate in the exercise sessions, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the exercise sessions.
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I agree
Initial Below: In consideration of being permitted to participate in the exercise sessions, I knowingly, voluntarily and expressly waive any claim I may have now or in the future against Samantha Zilvitis for injury or damages that I may sustain as a result of participating in the exercise sessions.
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I agree
Initial Below: I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Samantha Zilvitis for any injury or death caused by her negligence or other acts.
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I agree
I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
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Thank you for agreeing to the terms and conditions stated above. Please type out your full name.
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If participant is under 18 years of age. Name of Parent/Legal Guardian of Participant:
First Name
Last Name
Phone Number of Parent/Legal Guardian of Participant:
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Area Code
Phone Number
Signature of Parent/Legal Guardian of Participant
Parent/Legal Guardian: Thank you for agreeing to the terms and conditions stated above. Please type out your full name.
Submit
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