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(847) 460-2742

2679 Shermer Road
Glenview Illinois 60025

Waiver Form

360­athlete client

information and waiver

2679 shermer road

northbrook, il 60062

847 460­2742

​www.360­athlete.com

email……………………………………… birthdate……./…../…….. state…………………………..zip code……………………………. Are you medically cleared for strenuous exercise? (yes/no)

Do you have any medical restrictions on physical activity? (yes/no)

Parents Name…………………… cell phone ………………….

email………………………………..

relationship……………………………….. how did you hear about 360­athlete

friend …… coach…..website……socialmedia……. other…….

preferred method of payment ………………………………………………………………….. name on card ……………………………………………………………………………………. credit card type visa ……. mastercard……..discover……….

card # …………………………………………………………… expiration……./……/……..

Waiver, release, and assumption of risk form

This form is an important legal document. it explains the risk you are assuming by beginning an exercise program. it is critical that you read and understand it completely.after you have done so, please print your name legibily and sign in the spaces provided at the bottom.

waiver, informed consent and covenant not to sue

I, …………………………………………… have volunteered to participate in a program of physical exercise under the direction of 360­athlete which will include, but may not be limited to speed and or resistance training, in consideration of 360­athlete’s agreement to instruct,assist and train me. i do here and forever release and discharge and hereby hold harmless 360­athlete and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands,damages, rights of action or cause of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from. this waiver and release of liability includes without limitation injuries which may accur as a result of (1)equipment that may malfuntion or break

(2) any slip, fall,dropping of equipment and (3) negligent instruction or supervision.

Assumption of risk

I…………………………………… , recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. i acknowledge that the possibility of certain unusal physical changes during exercise does exist. these changes include abnormal blood pressure,fainting, disorders in heartbeat,heart attack, and in rare instances death . i understand that as a result of my participation in any exercise program. i could suffer an injury or physical disorder that could in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life. i recognize that an examination by my physician must be obtained prior to involvement in this exercise program. i acknowledge and agree that i assume the risk of associated with any and all activities and/or exercises in which i participate. i acknowledge and agree that no warranties or representations have been made to me regarding the results i will; achieve inform this program. i understand that results are individuals and may vary. i acknowledge that i have thoroughly read this waiver and release and fully understand that it is a release of liability. by signing this document. i am waiving any right i or my successors might have to bring a legal action or assert a claim against 360-­athlete for your negligence ,pr that of your employees,agents, or contractors

………………………………………………. .

……………………

participant’s signature ( parent/ guardian if under 18)

date

………………………..

………………………..

print name

coach name

publicity release

as a part of our program, we often videotape training session to help us in communicating technique and allow the clients to see how they are doing. from time to time, we put together some of those clips to be able to showcase some of the training that we do at 360­athlete. do you give the permission to 360­athlete to use your child’s name ,picture, statement, or video footage for the purpose of informing, promoting, or advertising the work that we do at

360­athlete

yes…….. no………….

initial ………..