Melrose Boot Camp Signup Form

Medical History & Waiver for Melrose Boot Camp

	First Name*
	Last Name*
	Email*
	Address*
	City*
	State*
	Zip*
	Phone*
	Age*
	Weight (lbs)*
	Height (in)*
	Emergency Contact*
	Emergency Phone Number*
	Current Medications*
	Medical Limitations*
	Running Currently*
	Running HS or College*
	Sports Played in Past*
	Current Sports, Workouts, Training*
	Injuries, Pain, Surgery*
	Heart Condition*		yes no
	High Blood Pressure*		yes no
	High Cholesterol*		yes no
	Stroke*		yes no
	Heart Attack*		yes no
	Chest Pain with Exercise*		yes no
	Chest Pain at Rest*		yes no
	Emphysema*		yes no
	Chronic Bronchitis*		yes no
	Diabetes*		yes no
	Pregnant*		yes no
	Smoker*		yes no
	Family Member Heart Attack*		yes no
	Please explain any ‘Yes’ answers above*
	Reason why you can’t or shouldn’t participate*
	Anything Else We Should Know*
	How did you hear about us? Please be specific so we can thank your friend if that’s how you heard about us.
	Date*
	Waiver Signature (I agree with the waiver below)*		yes no

INFORMED CONSENT & WAIVER

In consideration of me being permitted to participate in any way in the Melrose Boot Camp Training Activities (“Activity”), I agree:

1. I understand the nature of Strength & Conditioning or Personal Training activities and believe I am qualified to participate in such Activity. I further acknowledge that I am aware the activity will be conducted at my home, in a studio or outdoors during the Activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.

2. I FULLY UNDERSTAND that: (a) Strength & Conditioning and Personal Training Activities involve risks and dangers of SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH (“Risks”); (b) these Risks and dangers may be caused by my own actions, or inaction’s, the actions or inaction’s of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be other risks and social and economic losses either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES incurred as a result of my Participation in the Activity.

3. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS Dana Randolph, Joy Fay, Bernadette Farrell, Stacey Suntken, any respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises on which the Activity takes place (each considered one of the “Releasees” herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the “Releasees” or otherwise, including negligent rescue operations and further agree that if, despite this release, I, or anyone on my behalf makes a claim against any of the Releasees named above, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE OR COSTS ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.

4. Photo and video release: I hereby give my consent for Melrose Boot Camp to use photographs and/or video taken of me while engaged in Melrose Boot Camp activities for use in promotional materials such as a website and/or newspaper. I hereby waive my rights of compensation or ownership of these photographs and/or video.

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND IT’S TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.