PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED.

I have enrolled in a program of instruction utilizing CrossFit, strength training, and other methods of physical conditioning offered by Systematic Strength and Conditioning. I have been advised and I understand that participation in CrossFit, strength training, other methods of exercise and conditioning activities, like any physical conditioning activity or exercise program, presents some unavoidable risk of injury, especially to people who have pre-existing injuries, illness or medical disabilities. I understand that the use of exercise equipment also carries with it a risk of injury. I recognize that many changes may occur as a result of exercise lessons, including but not limited to possible short term aggravation of some symptoms, feeling of tiredness, light-headedness, change in energy level, mood changes, etc.

I also understand that a medical evaluation is advisable before commencing any program of physical conditioning or exercise. I have and will continue to keep the instructors and practitioners of Systematic Strength and Conditioning fully informed of any physical condition or disability, which would prevent or limit my participation in an exercise or physical conditioning program. I acknowledge that, although the program may have substantial physical benefits, Systematic Strength and Conditioning practitioners do not engage in diagnosing or treating medical diseases or deficiencies.

I expressly assume all risks of my participation in the program of CrossFit, strength training, and other methods of conditioning conducted by Systematic Strength and Conditioning and waive any claim which I might otherwise bring against Systematic Strength and Conditioning, its officers, directors, shareholders, employees, trainees and contractors, as a result of injuries resulting from or relating to my participation in this conditioning program.

I hereby waive and release Systematic Strength and Conditioning and its instructors and practitioners from any and all liability, past, present, and future relating to CrossFit, strength training, and other methods of exercise.

Systematic Strength and Conditioning and its practitioners shall not be responsible or liable for any articles lost, stolen or damaged.

Please understand that despite all the precautions that you, other members, and/or Systematic Strength and Conditioning may take, we cannot guarantee your health or safety, and you may still be exposed to COVID-19, including through interactions with other individuals who have COVID-19.  By executing this release and gaining access to the facility, you, on behalf of yourself, your heirs, beneficiaries, representatives, successors and assigns: (1) voluntarily assume all risks associated with any exposure to COVID-19, including, but not limited to suffering any type of medical condition, illness and, potentially, death; and (2) knowingly and voluntarily waive, release, covenant not to sue, forever discharge, indemnify, and hold harmless Systematic Strength and Conditioning, its parents and subsidiaries and their respective officers, directors, employees, contractors, agents, representatives, successors and assigns (“Released Parties”) from any and all liability, damages, losses, suits, demands, causes of action to the fullest extent permitted by the laws of this state, or any other claims of any nature whatsoever, arising out of or relating in any way to your use of the facility and your potential exposure to COVID-19.

Cancellation and Rescheduling Policy:
When canceling or rescheduling your appointment we respectfully request your consideration in providing us with a minimum 24 hour notice. We understand things come up, sick kids, sick spouses and the like. We are a true mom and pop establishment. Cancellations received less than 24 hours prior to your appointment will be charged the cost of the reserved service.
Emergency Contact Name:*
Emergency Contact Phone:*
Reason for Visit*
Are you currently receiving treatments from another medical provider? (ie. Home health, chiropractic, etc.) *
If yes, please explain:
Have you had any special medical tests or studies? (ie. X-Ray, MRI, etc.) *
If yes, please explain:
Do you have any previous medical history: (please explain, providing approximate dates)
During the past 5 years have you been admitted to hospital or had surgery?*
If yes, please provide the date and reason:
During the past 5 years have you had any previous orthopedic problems or injuries?*
If yes, please explain:
During the past 5 years have you received any physical therapy treatments?*
If yes, for what conditions?
During the past 5 years have you had any broken bones?*
If yes, please explain
Additional Information:
By typing your name, you are signing this form:*
Do you agree to the terms as stated above?*