Jump Registration, Consent, and Waiver Form

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Participant’s Name*

First NameLast Name

Have you already participated in a JUMP! session and filled out ALL of your waivers and information? Please select NO if this is your first session OR if you have already participated but need to fill out information/waiver for a NEW participant in your family.*

YES- Every participant in my family has filled out a waiver.NO- This is my first session or I have a new family member participating.

Birth Date*

MonthDayYear

Phone Number*

E-mail*

example@example.com

Contact Information

Is there another adult participating from your family?*

YESNO

Participant’s Name*

First NameLast Name

Birth Date*

MonthDayYear

Do you have a child/children that you need to register?*

YESNO

Participant’s Name*

First NameLast Name

Age*

Do you need to add another child?*

YESNO

Participant’s Name*

First NameLast Name

Age*

Do you need to add another child?*

YESNO

Participant’s Name*

First NameLast Name

Age*

Do you need to add another child?*

YESNO

Participant’s Name*

First NameLast Name

Age*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Emergency Contact Phone Number*

JUMP! Session Selection- Tuesday/Thursday ONLY (May 28th through August 1st) JotForm only allows one day at a time to sign up, please start a new form for each specific day you'd like to be registered for. After your first form is submitted you may skip to the day selection and payment by answering "YES" under your Name. Sorry for the inconvenience.*

Date

Hour MinutesAM/PM Option

Do you and/or your children have any allergies (pertaining to the outdoors and/or that is life threatening, ie- Bees), chronic illness, or medical conditions? If yes, please describe.*

Informed Consent and Acknowledgement - Adults

I/We hereby give my/our approval for my/our participation in any and all activities prepared by Rocky Mountain Health and Exercise, LLC during the exercise program "JUMP!". I/We assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Rocky Mountain Health and Exercise, LLC and all its respective officers, agents, and representatives from any and all liability for injuries arising out of participating in the selected exercise sessions.

In case of injury, I/we hereby waive all claims against Rocky Mountain Health and Exercise, LLC, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all exercise activities, including jump rope, cardiovascular, and strength exercises. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization - Adults

I/We hereby authorize the diagnosis and treatment by a qualified and licensed medical professional in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named participant(s). In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I/we understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Rocky Mountain Health and Exercise, LLC, and its affiliates including Exercise Physiologists and helpers, to provide the needed emergency treatment prior to admission to the medical facility.

Release authorized on the dates and/or duration of the registered program May 28, 2024 to August 1, 2024.

This release is authorized and executed of my/our own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb, in my/our inability to decide for myself/ourselves.

Informed Consent and Acknowledgement - All Children Registered

I hereby give my approval for my children's participation in any and all activities prepared by Rocky Mountain Health and Exercise, LLC during the selected exercise program. In exchange for the acceptance of said children’s candidacy by Rocky Mountain Health and Exercise, LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Rocky Mountain Health and Exercise, LLC and all its respective officers, agents, and representatives from any and all liability for injuries to said children arising out of participating in selected exercise sessions.

In case of injury to said children, I hereby waive all claims against Rocky Mountain Health and Exercise, LLC, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all exercise activities, including jump rope, cardiovascular, and strength exercises. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization - All Children Registered

As Parent and/or Guardian of the named participants who are minors, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor children, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named participants. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Rocky Mountain Helath and Exercise, LLC, and its affiliates including Exercise Physiologists and helpers, to provide the needed emergency treatment prior to any of my children’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered program May 28, 2024 until August 1, 2024.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor children, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

JUMP!

Participant Information

Participant Information

Participant Information

Participant Information

Participant Information

Participant Information