Special Strong® West Valley Registration with PAR-Q

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)*

Private TrainingPartner TrainingGroup ClassesAquaticsVirtual Training
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?*

FacebookInstagramInternet SearchVehicle WrapReferralOther
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*

YesNo
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?*

YesNo
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?*

YesNo
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.)*

YesNo
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*

YesNo
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?*

YesNo
Please provide more details about your condition or goals so we can better serve your needs.*
History of breathing or lung problems*

YesNo
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?*

YesNo
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?*

YesNo
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)*

YesNo
Please provide more details about your condition or goals so we can better serve your needs.*
Recent surgery (last 12 months)*

YesNo
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?*

YesNo
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)?*

YesNo
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?*

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

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
Current or recent pregnancy in the last six months*

YesNo
Fainting, lightheadedness, blackouts, seizure, or epilepsy*

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
Allergies: Check any allergies below*

LatexFood Allergies/IntolerancesMedicationEnvironmental (seasonal, dust, etc.)No Known AllergiesOther
Medications: List all current medications and supplements*
Top Three Health & Fitness Goals*
Behavioral Challenges*

Eloping or running awayAggression or self-injuryMeltdowns or tantrumsProperty destructionAnxiety or difficulty with transitionsRepetitive or obsessive behaviorsRefusal or noncomplianceSocial withdrawalSensory seeking or avoidanceN/A
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 Arizona.

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
Date
Signature*
Unique Code
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