Special Strong® West Valley Registration

Date

I am filling out these forms*

For Myself as a Participant who is over 18As a Parent or Legal Guardian on Behalf of a Participant who is a minor under 18As a Parent or Legal Guardian on Behalf of a Participant who is over 18

Which services are you interested in? (select all that apply)*

Participant Name*

First NameLast Name

Parent or Legal Guardian Name*

First NameLast Name

Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent or Legal Guardian Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Email Address*

example@example.com

Parent or Legal Guardian Email Address (if different than above)

example@example.com

Alternate Email Address

example@example.com

Cell Phone Number*

Area CodePhone Number

Parent or Legal Guardian Phone Number*

Area CodePhone Number

Participant Date of Birth*

Participant Height*

Participant Weight*

Participant Disability/Disease/Disorder *

How did you hear about us?*

Please share details about how you heard about us*

Please use the check boxes to indicate your availability, Monday-Saturday*

	Mon	Tues	Wed	Thur	Fri	Sat
8am-10am
10am-1pm
1pm-3pm
3pm-5pm
5pm-7pm

Primary contact*

First NameLast Name

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship to participant*

Participant is able to give consent for medical treatment in the event of an emergency*

YesNo

List the names (first, last) and location of any medical professionals you are currently seeing or have seen in the last year*

Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/or that you should only do physical activity recommended by a doctor?*

YesNo

Do you feel pain in your chest when you do physical activity?*

YesNo

In the past month, have you had chest pain when you were not doing physical activity?*

YesNo

Do you lose your balance because of dizziness or do you ever lose consciousness?*

YesNo

Do you ever experience loss of balance or unsteadiness while walking?*

YesNo

Do you require wheelchair transfers or the use of a gait belt?*

YesNo

Is your doctor currently prescribing medication for your blood pressure or heart condition?*

YesNo

Any medical implants (i.e., VNS or pacemaker)?*

YesNo

Is there a heart-rate range that is recommended or discouraged?*

YesNo

Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?*

YesNo

Do you have a diagnosed illness that could be made worse by physical activity?*

YesNo

Any chronic illness or condition (including diabetes or thyroid)*

YesNo

Difficulty or limitations (knee, hip, neck, back, foot problems, shoulder, etc.)*

YesNo

Recent surgery (last 12 months)*

YesNo

Current or recent pregnancy in the last six months*

YesNo

History of breathing or lung problems*

YesNo

Fainting, lightheadedness, blackouts, seizure, or epilepsy*

YesNo

Muscle, joint, or back disorder, or any previous injury still affecting you*

YesNo

Are there any movements or exercises recommended or discouraged by your doctor(s)?*

YesNo

Do you need medical clearance before you can begin an exercise program?*

YesNo

Do you know of any other reason why you should not do physical activity?*

YesNo

If you answered “yes” to any of the questions above, please provide details or type N/A*

Allergies: Check any allergies below*

Medications: List all current medications and supplements*

Top Three Health & Fitness Goals*

Behavioral challenges*

ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT (“Agreement”)

This Agreement is entered into between Special Strong LLC (“Special Strong”) and the individual named below (“Client”). Special Strong’s provision of individual and/or group fitness training services, which may be provided and performed in person and/or remotely (collectively, the “Services”) to Client and Client’s participation in the Services are contingent upon the execution of this Agreement. Each person participating in the Services must execute this Agreement, which includes anyone participating in the activities solely to assist Client in Client’s participation in the Services. Herein, the term “Client” also includes, (i) the Client’s parent or legal guardian if such person is executing this Agreement on Client’s behalf, and (ii) the Client’s parent, legal guardian, caregiver, or other authorized individual who is assisting Client in Client’s participation in the Services. Additionally, herein, the term “Special Strong” includes Special Strong and Special Strong’s officers, agents, owners, parent entities, subsidiaries, affiliates, franchisees, contractors, and employees.

Assumption of Risk: Please read this Agreement carefully and be aware that by participating in the Services, or by registering to participate in the Services (either for Client or on behalf of another) Client acknowledges and agrees that if the Client engages in any physical exercise or activity, including the Services, or enters into Special Strong’s premises or uses any facility or equipment on Special Strong’s premises for any purpose, or any facility and/or equipment made available to Client, then Client does so at their own risk and assumes the risk of any and all injury and/or damage Client may suffer, whether while engaging in the Services or physical activity, or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided by Special Strong or otherwise, including injuries or damages arising out of the negligence of Special Strong, whether active or passive.

Client agrees that they are voluntarily participating in the Services and assumes all risk of injury, illness, damage, or loss to Client and/or Client’s property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence or gross negligence of Special Strong or otherwise.

Release of Liability: Client, on behalf of him/herself, and all of Client’s personal representatives, parents, guardians, heirs, executors, administrators, agents, and assigns, hereby releases and forever discharges Special Strong of and from all manner of actions, disputes, causes of action, suits, claims (specifically including, but not limited to, claims for negligence, claims for gross negligence, claims for personal injury, and claims for mental anguish), counter-claims, cross-claims, interest, costs, judgments, executions, liabilities, losses, obligations, damages (including, but not limited to, reasonable attorney’s fees, lost wages, expenses for medical treatment, loss of consortium, and mental anguish damages) and demands of any character, type, or description, in law or in equity, at common law, statutory or otherwise, including, negligence and/or gross negligence, for any damages arising out of or in any way connected with Client’s participation in the Services, including but not limited to property damage, personal injury, and/or death.

Indemnification: CLIENT, TO THE FULLEST EXTENT PERMITTED BY LAW, SHALL INDEMNIFY AND HOLD HARMLESS SPECIAL STRONG FROM AND AGAINST ANY AND ANY LOSS, LIABILITY, DAMAGE, COST, LAWSUIT AND/OR EXPENSE (INCLUDING REASONABLE ATTORNEY’S FEES) SPECIAL STRONG MAY INCUR DUE TO THE PROVISION OF THE SERVICES TO CLIENT.

Consent to Treatment: If in the case of an emergency, Client (or Client’s emergency contact) cannot be reached, Client authorizes Special Strong to obtain whatever medical treatment they reasonably deem necessary for the welfare of Client, including but not limited to first aid and/or CPR. Client further understands and agrees that Client will be financially responsible for all charges and fees incurred for the provision of such medical treatment.

ACKNOWLEDGMENT: Client expressly agrees that this Agreement is intended to be as broad and inclusive as permitted by the law in the State of Texas and that if any portion thereof is held invalid, it is agreed that the remaining provisions shall, notwithstanding, continue in full legal force and effect.

Governing Law: Special Strong and Client agree that this Agreement is governed by the laws of the State of Texas without reference to rules governing choice of laws.

AGREEMENT

I HAVE READ AND UNDERSTAND THE ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT. I AGREE WITH ALL PROGRAM REQUIREMENTS.

CLIENT (OR, IF A PARENT OR LEGAL GUARDIAN IS SIGNING THIS AGREEMENT ON THE CLIENT’S BEHALF) HAS READ AND REVIEWED THIS AGREEMENT AND VOLUNTARILY AGREES TO BE BOUND BY ITS TERMS. ADDITIONALLY, CLIENT (OR THE APPLICABLE PARENT OR LEGAL GUARDIAN) EXPRESSLY ACKNOWLEDGES THAT THE UNDERSIGNED IS WAIVING NEGLIGENCE CLAIMS, GROSS NEGLIGENCE CLAIMS, PERSONAL INJURY CLAIMS, AND MENTAL ANGUISH CLAIMS AGAINST SPECIAL STRONG.

MY SIGNATURE REPRESENTS THAT I AM AT LEAST 18 YEARS OF AGE, AND HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS, AND WILL EXECUTE THIS AGREEMENT.

Print Name*

First NameLast Name

Date Signed*

Date

Signature*

Unique Code

Special Strong® West Valley Registration

EMERGENCY CONTACT INFORMATION

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)