Special Strong® Folsom California Registration with PAR-Q

Special Strong® Folsom California Registration
Date
I am filling out these forms
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 Disability/Disease/Disorder
How did you hear about us?

Other
Please share details about how you heard about us

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

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

EMERGENCY CONTACT INFORMATION
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
List the names (first, last) and location of any medical professionals you are currently seeing or have seen in the last year
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
Do you have any visual impairments?
Please provide more details about your condition or goals so we can better serve your needs.
Do you require wheelchair transfers or the use of a gait belt?
Please provide more details about your condition or goals so we can better serve your needs.
Difficulty or limitations (knee, hip, neck, back, foot problems, shoulder, etc.)
Please provide more details about your condition or goals so we can better serve your needs.
Muscle, joint, or back disorder, or any previous injury still affecting you
Please provide more details about your condition or goals so we can better serve your needs.
Do you feel pain in your chest when you do physical activity?
Please provide more details about your condition or goals so we can better serve your needs.
History of breathing or lung problems
Please provide more details about your condition or goals so we can better serve your needs.
Do you lose your balance because of dizziness or do you ever lose consciousness?
Please provide more details about your condition or goals so we can better serve your needs.
Do you ever experience loss of balance or unsteadiness while walking?
Please provide more details about your condition or goals so we can better serve your needs.
Any chronic illness or condition (including diabetes or thyroid)
Please provide more details about your condition or goals so we can better serve your needs.
Recent surgery (last 12 months)
Please provide more details about your condition or goals so we can better serve your needs.
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Please provide more details about your condition or goals so we can better serve your needs.
Are there any movements or exercises recommended or discouraged by your doctor(s)?
Please provide more details about your condition or goals so we can better serve your needs.
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?
In the past month, have you had chest pain when you were not doing physical activity?
Any medical implants (i.e., VNS or pacemaker)?
Is there a heart-rate range that is recommended or discouraged?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Current or recent pregnancy in the last six months
Fainting, lightheadedness, blackouts, seizure, or epilepsy
Do you need medical clearance before you can begin an exercise program?
Do you know of any other reason why you should not do physical activity?
Allergies: Check any allergies below

Other
Medications: List all current medications and supplements
Top Three Health & Fitness Goals
Behavioral Challenges
Behavioral challenges
ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT
Strong Kingdom LLC dba Special Strong

This Agreement is between Strong Kingdom LLC dba Special Strong (“Special Strong”), the independently owned and operated franchisee (“Franchisee”), and the individual named below (“Client”).

The Services include individual and/or group fitness training provided in person or remotely (“Services”). Each participant must sign this Agreement, including anyone assisting the Client.

Definitions
“Client” includes the participant, their parent, guardian, caregiver, or authorized representative.
“Special Strong” includes Strong Kingdom LLC dba Special Strong, its officers, owners, employees, agents, and affiliates.
“Franchisee” refers to the local franchise owner and their staff providing the Services.

Assumption of Risk
Client understands that participating in fitness activities involves risk of injury, illness, or property damage. This includes risks from using equipment or facilities, or from the actions of others. Client voluntarily assumes all risks, including those caused by the negligence of Special Strong or the Franchisee.

Release of Liability
Client releases and discharges Special Strong, the Franchisee, and all associated persons from any and all claims, including those related to negligence, personal injury, mental anguish, or death, that arise from participation in the Services.

Indemnification
Client agrees to indemnify and hold harmless Special Strong and the Franchisee from any loss, liability, damage, or cost, including attorney’s fees, resulting from Client’s actions or participation in the Services.

Franchisee Protection
The Franchisee is entitled to the same legal protections as Special Strong. This Agreement applies equally to protect the Franchisee from claims unless they result from gross negligence or willful misconduct.

Consent to Emergency Medical Treatment
If Client cannot be reached in an emergency, they authorize Special Strong or Franchisee staff to seek necessary medical treatment. Client agrees to be responsible for any costs incurred.

Governing Law
This Agreement is governed by the laws of the State of California.

Photo and Video Release
Client gives permission for Special Strong and the Franchisee to use photos, audio, and video recordings for educational or promotional purposes without compensation. This release has no expiration and may include online use. Client understands they may be contacted for uses beyond this scope.

Acknowledgment
By signing below, Client confirms they have read, understood, and agree to the terms of this Agreement.
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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Unique Code
Should be Empty: