Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Name

First Name

Last Name

Do you have a medical condition/s that may effect your health or ability to undertake a regular exercise program? *

Yes

No

Are you currently taking a prescribed medication that may effect your ability to safely participate in a regular exercise program.

Yes

No

What's your main motivation in participating for an exercise program with CrossFit Tully? *

Social

Improve sport specific skills

Improve general fitness and health

Reduce Body Fat

Lower health related risk factors

Other

Client: The client acknowledges and undertakes to: (A) Accurately complete the medical screening questionnaire to the best of the client’s ability and promptly advise the Fitness Centre of any health changes, concerns or new injuries prior to participating in any training session. (B) Provide the Fitness Centre, upon reasonable request, with written medical clearance from the client’s General Practitioner. *

I understand and AGREE

I understand and DO NOT AGREE

Liability Waiver: The client further acknowledges and agrees that due to the nature of the activity it would be unreasonable for CrossFit Tully or any of it's servants or agents to be in any way responsible for any injury to, or death of the client. The client hereby, to the full extent permitted by law, waives all of his or her legal rights of action against and fully releases CrossFit Tully or it's servants or agents for loss, damages, injury or death howsoever arising out of or in relation to the participation by the client in the activities conducted or organized by CrossFit Tully or any of it's servants or agents including without limitation, liability for any negligent or tortuous act or omission, breach of duty, breach of contract or breach of statutory duty on the part of CrossFit Tully or any of it's servants or agents. *

I understand and AGREE

I understand and NO NOT AGREE

Name *

First Name

Last Name

Agreement Date *

MM

DD

YYYY