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Breakthru Fitness, LLC
Full Name
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Email Address
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Phone Number
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In case of emergency, who should we contact? Please provide name and relation to you.
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Emergency Contact Number
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How did you hear about Breakthru Fitness?
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Has your doctor ever told you that you have a bone or joint problem (such as arthritis) that has been or may be exacerbated by physical activity?
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Yes
No
Has your doctor ever told you that your blood pressure was too high?
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Yes
No
Do you have high cholesterol?
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Yes
No
Has your doctor ever said you have heart trouble?
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Yes
No
Are you over 65 years of age and not accustomed to vigorous exercise?
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Yes
No
Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program?
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Yes
No
Buyer acknowledgment and assumption of risk and full release from liability BreakThru Fitness, LLC. Buyer acknowledges these physical activities involves the inherent risk of physical injuries or other damages, including, but not limited to heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heart prostration, knee/lower back/foot injuries and any other illness, soreness, or injury however caused, occurring during or after buyer's participation in the physical activities. Buyer further acknowledges that such risks include, but are not limited to, injuries caused by the negligence of an instructor or other person, defective or improperly used equipment, over-exertion of a buyer, slip and fall by buyer, or an unknown health problem of buyer. Buyer agrees to assume all risk and responsibility involved with participation in the physical activities. Buyer affirms that buyer is in good physical condition and does not suffer from any disability that would prevent or limit participation in the physical activities. Buyer acknowledges participation will be physically and mentally challenging, and buyer agrees that it is the responsibility of buyer to seek competent medical or other professional advice, regarding any concerns or questions involved with the ability of buyer to take part in BreakThru Fitness, LLC physical activities. By signing this agreement, buyer asserts that he or she is capable of participating in the physical activities. Buyer agrees to assume all risk and responsibility for not exceeding his or her physical limits. SIGN BELOW
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