top of page

Adult Health Waiver

All information given is personal and confidential. It will enable us to better understand your health and fitness habits. In addition, we will use this information to classify your health status according to the American College of Sports Medicine in ACSM's Guideline for Exercise Testing and Prescription (2021).


Adult Health Waiver Form
Client Contact Information
Personal Health History

Enter as accurately as possible.

Are you presently taking any medications?
Are you a current smoker (includes vaping, cigarettes, and/or chewing tobacco)
High Blood Pressure (Systolic Blood Pressure > or = to 140mmHg OR Diastolic > or = to 90mmHg)
High Blood Cholesterol (Total serum cholesterol < 200mg.dl-1)
Diabetes Mellitus
Do you have or had any of the following?
Family History 

Check each as it applies to a blood relative.

Heart Attack
Sudden Death

I understand and acknowledge that physical exercise can be strenuous and will subject me to risk of serious injury, and that I am urged to obtain a physical examination from a doctor before participating in any exercise activity.  I agree that I engage in any physical exercise and other activities entirely at my own risk.  I agree that I am voluntarily participating in these activities and assume all risks of injury, illness or death.

Any recommendation for changes in diet including the use of food supplements and weight reduction products are entirely my responsibility and I should consult a physician prior to undergoing any dietary or food supplement changes.


This waiver and release of liability includes, without limitation, all injuries which may occur as a result of: (a) my participation in any exercise and/or other activity or personal training session and (b) instruction, training, or supervision by any representative of ANCHOR life + fitness, LLC.


I acknowledge that I have carefully read this waiver and fully understand that it includes a release of liability.  I hereby expressly agree to release and discharge Anchor Life and Fitness, LLC, its officers, members, representatives, agents and employees, from any and all claims or causes of action for death, personal injury and/or property damage which may result from or may otherwise be related in any way or manner to (a) my participation in any exercise and/or other activity or personal training session and (b) instruction, training, or supervision by any representative of ANCHOR life + fitness, LLC., and I agree to voluntarily give up or waive any right that I may otherwise have to bring a legal action for death, personal injury or property damage without exclusion and from whatever cause, including but not limited to the sole or contributory negligence of any officer, member, representative, agent and/or employee of ANCHOR life + fitness, LLC.


If any portion of this waiver shall be deemed by a Court of competent jurisdiction to be invalid, the remainder shall remain in full force and effect and the offending provision or provisions severed.


By signing this waiver, I acknowledge that I understand its content and that it cannot be modified orally.

Social Media Waiver

Client hereby permits ANCHOR life + fitness to create and/or obtain and use without compensation my photograph and/or other likeness, including but not limited to video and electronic recording likenesses, voice, and/or quotes/excerpts of my verbal or written statements or words created at, from or related to activities connected in any manner with ANCHOR life + fitness (collectively my “Likeness”) for purposes related to the business and training missions of ANCHOR life + fitness, including but not limited to advertisement, instruction and/or education, publicity, marketing and promotion. I understand my likeness may be copied/reproduced and distributed by broadcast/rebroadcast, radio, transmission/retransmission, news, releases, mail-outs, emails, billboards, signs, brochures, placement on websites and/or other electronic delivery, publication, display and/or promotion on any and all other media, subject to reasonable modification and editing. I waive any right to inspect or approve the finished product or material in which ANCHOR life + fitness may eventually use my Likeness. I relinquish and give to ANCHOR life + fitness, its successors and assigns, all right, title and interest to my Likeness including any copyright therein.

My signature below certifies the information provided on and in connection with this form is true and correct to the best of my knowledge. I also agree to the aforementioned terms and conditions listed above.

bottom of page