Short Term Program Sign up form and Indemnity/ Health Release Name* First Last Date of Birth* YYYY MM DD Cell*Email* Referred by*Referred byCurrent EFF Boot Camp MemberFriend/FamilyFacebookTwitterInstagramWebsitePass ByEmailCurrent Member* Program*Select program14 Day Program16 Day Program21 Day Program28 Day ProgramFamily History1. Do you have a family history (parent or siblings) of heart of metabolic disease?* No, non apply High Cholestrol Stroke Non-Insulin Dependent Diabetes High Blood Pressure Insulin Dependent Diabetes Heart Disease Personal Medical History2. Have you ever suffered from any heart, respiratory or metabolic condition?* No, non apply High Cholestrol Stroke Non-Insulin Dependent Diabetes High Blood Pressure Insulin Dependent Diabetes Heart Disease Cancer Other Lung Disease Asthma Peripheral Vascular Disease (Inflammations in the veins) 3. Do you currently experience any symptoms of respiratory or cardiovascular disease?* No, non apply Chest Pain Palpitations Ankle Swelling Intermittent Claudication (Leg cramps during walking) Frequent fainting or Dizzy Spells Shortness of Breath 4. Do you currently experience any general medical symptoms?* No, non apply Flu-like Symptoms Other Significant Symptoms 5. Do you currently suffer from any symptoms of joint injury or joint disease?* Yes No 6. Are you currently pregnant?* Yes No Risk Factors7. Are you a current smoker or have you smoked within the last 6 months?* Yes No 8. Do you do less than 3 hours of physical activity per week? (Including housework, gardening etc.)* Yes No Please Note: It is the responsibility of the participant to inform the fitness or health professional of any changes in health status.Indemnity Waiver | Terms and Conditions Terms and Conditions. Thank you for investing in Explosive Functional Fitness Boot Camp training; we appreciate your focus and dedication to achieving your goals and look forward to a great training relationship. Please take note of the following terms and conditions that will create the foundation and guidelines for your training time with us. Health Concerns. Prior to, or during the course of your training, health concerns may arise that need further input from your doctor, physiotherapist or other allied health professionals. Your trainer may request your assistance in obtaining that information. If a particular exercise is uncomfortable or painful for you to do or you have an injury, you may stop. Please ensure you have sufficient water during the training sessions. No Liability / Indemnity By ticking this registration form, you have volunteered to participate in a program of physical exercise under the direction of Explosive Functional Fitness Bootcamp (PTY) Ltd and/or its’ staff and/or its Instructors which will include, but may not be limited to, weight and/or resistance training. In consideration with Explosive Functional Fitness Boot Camp’s agreement to instruct, assist, and train you, you hereby and forever release and discharge and hold harmless Explosive Functional Fitness Bootcamp (PTY) Ltd and/or its’ Instructors from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with your participation in this or any exercise program, including any injuries resulting therefrom. You understand and are aware that strength, flexibility and aerobic exercise, including the use of equipment, is a potentially hazardous activity. You also understand that fitness activities involve a risk of injury and even death, and that you are voluntarily participating in these activities and using equipment with knowledge of the dangers involved. You hereby agree to expressly assume and accept any and all risks of injury or death. You further declare that you are physically sound and suffering from no condition that would prevent you from participation or use of equipment. You acknowledge that you have either had a physical examination and have been given Doctors permission to participate, or that you have decided to participate in activity and use equipment without the approval of your Doctor and do hereby assume all responsibility for your participation and activities, and utilisation of equipment in your activities. You are also aware that Explosive Functional Fitness Bootcamp (PTY) Ltd may record workouts for later use on television segments, websites, promotional materials or in any other way they see fit. By signing acceptance of these terms and conditions, you hereby authorize Explosive Functional Fitness Bootcamp (PTY) Ltd to use your name and likeness, voice, verbal statements, video-taped pictures for any of the aforementioned purposes. Right of admission is reserved to EFF bootcamp. YOU ACKNOWLEDGE THAT YOU HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY TICKING ACCEPTANCE OF THIS INDEMNITY / HEALTH SCREENING FORMS, YOU ARE WAIVING ANY RIGHT YOUR SUCCESSORS OR YOU MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST EXPLOSIVE FUNCTIONAL FITNESS BOOTCAMP (PTY) LTD AND/OR ANY OF ITS STAFF AND/OR INSTRUCTORS. * I have read and accept the Terms and Conditions MEMBERS’ SIGNATURENameThis field is for validation purposes and should be left unchanged. Δ Read Indemnity Waiver/ Terms and Conditions
