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Alexis C. Gaston
Jen Bricker Simpson
Jaqui Griffith
Chris Maignan
Marney Richards
Katy Mockler
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JGF Athlete Waiver
First Name
Last Name
Email
Phone
Occupation
Address
Age
Birthday
Physician's Name
Physician's Phone
Date of Last Physical
Emergency Contact
I was referred by:
Emergency Contact's Phone
Health & Fitness Program
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Reason for your visit:
Injury and Medical Treatment History
Physical Activity Readiness Questionnaire
Have you ever had any form of heart disease?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have diabetes?
*
Yes
No
Do you have an abnormal resting EKG?
*
Yes
No
Have you ever experienced shortness of breath or chest pain?
*
Yes
No
Has a doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise?
*
Yes
No
Do you often feel faint or have spells of diziness?
*
Yes
No
Do you have high cholesterol?
*
Yes
No
Do you have a family history of heart disease?
*
Yes
No
Are you active?
*
Yes
No
Do you currently smoke or have you smoked in the past?
*
Yes
No
Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?
*
Yes
No
Are you over age 65 and not accustomed to vigorous exercise?
*
Yes
No
I have read and answered the "Physical Activity Readiness Questionnaire." I understand that if I answered yes to any question, vigorous exercise or exercise testing should be postponed. Medical clearance may be necessary.
*
Yes
No
Additional Health History
How often are you active or do you exercise?
Describe your typical activities or exercises.
Are you currently taking any medication?
*
Yes
No
Do you have any allergies?
*
Yes
No
Do you have any problems in following areas? Select all that apply.
Knees
Low Back
Neck/Shoulders
Hips/Pelvis
Flexibility
None
If you answered "Yes" to any of the questions above, please explain.
Are you currently under the care of a health professional?
*
Yes
No
Health Care Provider's Name
Health Care Provider's Phone
Just Get Fit Media Release
I grant Just Get Fit, LLC dba Just Get Fit and all its representatives and employees the right to photograph and video me. I authorize Just Get Fit, LLC dba Just Get Fit to copyright, use and publish photos and videos taken. I agree the use of photographs of me with or without my name for any lawful purpose, including but not limited to publicity, illustration, advertising, and web content.
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Waiver of Liability and release
I agree to participate in Just Get Fit, LLC d/b/a Just Get Fit’s (“Just Get Fit”) health and fitness program with a nationally certified and/or licensed health and fitness professional (group exercise instructor /licensed massage therapist: FL License #_____________/ personal fitness trainer).
Because physical exercise can be strenuous and subject to risk of injury, including serious injury (including, but not limited to musculoskeletal and/or cardiorespiratory systems or death, I understand that Just Get Fit urges me to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. I hereby certify that I know of no medical problems that would increase my risk of illness and injury as a result of participation in a health and fitness program designed by Just Get Fit. I understand and have been informed that there exists the possibility of adverse changes during any health and fitness program. I have been informed that these changes may include abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and instances of heart attack or death. I agree that if I engage in any physical exercise or activity, or use any amenity on Just Get Fit’s premises or off such premises, including any sponsored event, I do so entirely at my own risk. I agree that I am voluntarily participating in such activities and use of these facilities and assume all risk of injury, illness, or death. Just Get Fit is also not responsible for any loss, damage, or disappearance of your personal property.
Likewise, I acknowledge that dietary modifications can cause a variety of changes and can create problems, including as it relates to energy, stamina, appetite, and mood. Any changes in diet including the use of food supplements, weight reduction and/or body building enhancement products are entirely my responsibility and I acknowledge that I should consult a physician prior to undergoing any dietary or food supplement changes. I agree to waive, release, remise and discharge Just Get Fit and each associated health and fitness professional of any and all claims, demands, actions or damages of any kind resulting from: (a) my use of any amenities and equipment in Just Get Fit’s facility and my participation in any activity, class, program, personal training or instruction; (b) the sudden and unforeseen malfunctioning of any equipment; (c) Just Get Fit’s instruction, training, supervision, or dietary recommendations; (d) any on-line or virtual training; or (e) my slipping and/or falling while on Just Get Fit’s premises, including adjacent sidewalks and parking areas. This waiver also includes any claim associated with the presence of or transmission of any bacteria, viruses, or infectious diseases. By signing below, I acknowledge that I have carefully read this Waiver of Liability and Release and fully understand that it is a release of Just Get Fit’s liability. I expressly agree to release and discharge Just Get Fit, and all of its affiliates, employees, agents, representatives, successors, or assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I may otherwise have to bring a legal action against any of the foregoing for negligence, personal injury or property damage.
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