Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Do You Smoke?

Yes

No

Do You Drink?

Yes

No

Previous Injuries or Surgeries?

Yes

No

Do You Take Prescription Medication? *

Yes

No

Are You Currently Exercising? *

Yes

No

Do You Play Sports?

Yes

No

Do You Have: Back Pain, Neck Pain, or Shoulder Pain? *

Yes

No

Do You Have: High Blood Pressure, Asthma, or a Heart Condition? *

Yes

No

Any Other Conditions Not Listed? *

Yes

No

Photography/Video Release *

Participants involved in any activities offered by Evernox Fitness may be photographed or videotaped during trained. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Evernox Fitness website in any editorial, promotional or advertising material produced and/or published by Evernox Fitness.

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Waiver and Release of Liability

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. These risks include, but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, my training partner, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under direction of Evernox Fitness. I acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others. Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by Evernox Fitness, I, the undersigned hereby release Evernox Fitness, their principles, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. This agreement shall be binding up on me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect. If I am signing on behalf of a minor child, I also give full permission for any person connected with Evernox Fitness to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and/or surgical care for the child and to transport the child to a medical facility deemed necessary for the well-being of the child. Indemnification: The participant recognizes that there is risk involved in the types of activities offered by Evernox Fitness. Therefore the participant accepts financial responsibility for any injury that the participant may cause either to him/herself to any other participant due to his/her negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney.

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