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Athlete 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).

 

Athlete Health Waiver Form
Athlete and Parent/Guardian Contact Information
Athlete Personal Health History

Enter as accurately as possible.

Is the athlete presently taking any medications?
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?
Athlete's Family History 

Check each as it applies to a blood relative.

Heart Attack
Sudden Death
Deceased
Waiver

I understand and acknowledge that physical exercise can be strenuous and will subject my child to risk of serious injury, and that I am urged to obtain a physical examination from a doctor for my child before they participate in any exercise activity.  I agree to my child engaging in any physical exercise and other activities entirely at their own risk.  I agree that my child is 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 for my child and I should consult a physician prior to undergoing any dietary or food supplement changes for them.

 

This waiver and release of liability includes, without limitation, all injuries which may occur as a result of: (a) my child's 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 for my child.  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 child's 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

Social Media Waiver I hereby grant ANCHOR life + fitness permission in perpetuity to use my child’s photograph/ video image in any and all publications for ANCHOR life + fitness, including web site entries, without payment or any other consideration. I hereby authorize ANCHOR life + fitness to edit, copy, exhibit, publish or distribute all photos and images. I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my child’s photo appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph or video images. I hereby hold harmless and release and forever discharge ANCHOR life + fitness from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf, my child’s behalf, or on behalf of my estate which may have or may have by reason of this authorization.

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

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