Health Profile Form

Full name*

Date of Birth*

Date

Address*

Mobile*

Email*

example@example.com

Emergency contact name & number*

Have you ever had any form of heart disease?*

YesNo

Have you ever experienced shortness of breath or chest pains?*

YesNo

Do you have any current injuries actively being treated by a physician?*

YesNo

Do you have any allergies to latex or metals?*

YesNo

Do you have high blood pressure?*

YesNo

If you answer yes to any of these questions please provide more information below

WAIVER AND RELEASE OF LIABILITY

In consideration of ESPAofAL allowing me to participate, I acknowledge, understand and I am aware that: Ihave voluntarily chosen to participate in training activities provided by ESPAofAL. I understand there are inherent risks in all aspects of physical training and I acknowledge that I have been informed of the possible strenuous nature ofthe training and the potential for undesirable physiological results including. but not limited to, abnormal blood pressure, muscle soreness, fainting. heart attack and/or death.

I understand that the training may involve weight lifting, gymnastic movements, strenuous body weight exercises and other high exertion activities, and that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should Ifeel light-headed, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my coach. I give ESPAofAL and the staff of the facilities I train in permission to seek emergency medical services for me should I become injured or ill with the understanding that I am responsible for any expenses incurred.

I agree to WAIVE ANY AND ALL CLAIMS that I have or may have in the future against ESPAofAL, its officers, employees, agents, volunteers and independent contractors (all of whom are hereinafter collectively referred to as "the Releasees" I agree to RELEASE THE RELEASEES from any and all liability for any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer as a result of my participation in the programs, activities and services provided by ESPAofAL, due to any cause whatsoever including negligence, breach of contract, or breach of any statutory or other duty of care.

I agree to HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any damage to the property of, or personal injury to, any third party, resulting from my participation in any program, activity or service provided by the releases.

This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. 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. If I am signing on behalf of a minor child, I also give full permission for any person connected with ESPAofAL to administer first aid/CPR deemed necessary, and in case of serious illness or injury. I give permission to callfor medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.

Use of picture(s)/film/ikeness: I agree to allow ESPAofAL, its agents, officers, principals, employees and volunteers to use picture(s), film and/or likeness of me for advertising purposes. In the event I choose not to allow the use of the same for said purpose, I agree that must inform ESPAofAL of this in writing.

Please Initial if YES to ALL

Please Initial if YES to all EXCEPT PLEASE NO PICTURES**

I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS "INFORMED CONSENT FORM" I AM WAIVING CERTAIN LEGAL RIGHTS (INCLUDING THE RIGHT TO SUE) WHICHI OR MY HEIRS, NEXT OF KIN, EXECUTOR, ADMINISTERS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES. ANY QUESTIONS I HAD WERE ANSWERED TO MY FULL SATISFACTION.

Signature of Participant*

Date*

Date