The following invoice shows what you will be charged as you select on-ramp classes.
Gerbino & Halper, LLC doing business as CrossFit Bane
City, State, Zip: ______________________________________________
Date of Birth:
___________________________ Home Phone # : ___________________________ Cell
Phone # : ____________________________
In an Emergency, please call this
person: ______________________________________ Phone # : ____________________
How did you hear about us? :
(circle appropriate answer)
Do you: Smoke? Yes No
Drink alcohol? Yes No
Take prescription meds? Yes No
Currently exercise? Yes(How much per week? ________ ) No
sports? Yes No
Do you have: Previous Injuries or Surgeries? Yes No Explain: ________________________________________
High blood pressure, Asthma, Diabetes, or a Heart
condition? Yes No Explain: ________________________________________
Any other health conditions not listed? Yes No Explain: ________________________________________
Do you have problems in the following areas? If so,
Is there any reason you know
of that you should not participate in exercise?
Yes No Explain:
Bane recommends that you clear your participation in any exercise program with
Please tell us what your goals are/what you would like
gain from CrossFit Bane.
Participants involved in any
activities offered by CrossFit Bane may be photographed or videotaped during
training. The undersigned hereby consents to the use of these photographs
and/or videos without compensation, on the CrossFit bane website or in any
editorial, promotional or advertising material produced and/or published by CrossFit
Waiver and Release of Liability
Express assumption of risk: CrossFit Bane
made me fully aware that the fitness programs/classes which CrossFit Bane
offers and in which I desire to participate are of a nature and kind that are
extremely strenuous and can/may push me to the limits of my physical abilities.
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 CrossFit Bane.
I acknowledge and represent
that I have no physical impairments, injuries, or illnesses that will endanger
me or others. I agree to assume any and all risk associated with my
participation in CrossFit Bane fitness programs/classes.
Acknowledging of the above mentioned risks and hazards and in full consideration
of the fact that I am willingly and voluntarily participating in the activities
offered by CrossFit Bane and with my full understanding of all of the above, I,
the undersigned hereby waive, release, remise, and discharge CrossFit Bane,
their principals, 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 upon 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 CrossFit Bane 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.
I recognize that there is risk involved in the types of activities offered by CrossFit
Bane. Therefore the I accept financial responsibility for any injury that the I
or the participant may cause either to him/herself or to any other participant
due to his/her negligence.
I agree to indemnify and hold
harmless CrossFit Bane, their principals, agents, employees, and volunteers
from liability for the injury or death of any person(s) and damage to property
that may result from my negligent or intentional act or omission while
participating in activities offered by CrossFit Bane, at the main building or
abroad. This includes but is not limited to parks, recreational areas,
playgrounds, areas adjacent to main building, and/or any area selected for
training by CrossFit Bane. Should the above mentioned parties, or anyone acting
on their behalf, be required to incur attorney’s fees and costs to enforce this
agreement, I agree to reimburse them for such fees and costs.
I have read and understoodthe foregoing assumption of risk, and release of liability and I understand
that by signing it obligates me to indemnify the parties named for any
liability for injury or death of any person and damage to property caused by my
negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.
Signature of participant:
If the participant is under
the age of 18,
Signature of Parent/Guardian:
____________________________________ Print Name: ______________________________Date:_____________