Pre-Exercise Questionnaire & Waiver

Privacy Act: All Personal information provided on this form is treated as confidential. This information will not be passed on to any other person or company outside of CrossFit Eora. There may be occasion when staff may contact you or your Emergency Contact Person at your family home/work/mobile phone number in case of emergency or regarding requests or needs concerning yourself.

Your Details
Full Name
DOB
Mobile
Email

Emergency Contact
Mobile
Relation to you

Please check the box if you answer YES to any of the following:

 Is there anyone in your family under 60 whom suffered Heart Disease, Stroke, or Sudden Death?
 Are you male over 35, or female over 45 and NOT used to vigorous exercise?

 Do You Smoke?
 Are you taking any medication?
 Are you pregnant or have given birth in the last 6 weeks?

Are there any other conditions or health issue that may have an impact on your training?

Do you have any injuries or conditions in the following areas? Please indicate if YES;

 Head
 Neck
 Shoulder
 Arms/Elbow/Wrist
 Hips
 Knees
 Ankles/Feet

Agreement & Release of Liability

I wish to participate in the activities and programs of CrossFit Eora, I understand that portions of the exercise and training program may occur outdoors; and
exercise carries some risk including, without limitation, risk to the musculoskeletal system and to the cardio respiratory system.

In consideration of CrossFit Eora agreeing to provide training and fitness activities and programs, I release CrossFit Eora, its employees and representatives from any and all responsibilities or liability from injuries or damages resulting from or ancillary to my participation in any activities or my use of the equipment.

I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury or death, and that I am voluntarily participating in these activities and using equipment with knowledge of the dangers involved. I agree to expressly assume and accept any and all risk of injury or death.

I further declare myself to be physically sound and suffering from no condition, impairment, disease, or other illness that would prevent my participation in exercise programs or use of equipment.

I acknowledge that I have been informed of the need for a physician’s approval for my participation in and exercise of fitness activity or in the use of exercise equipment. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity exercise and use of exercise and training equipment, so that I might have his/her recommendations concerning these fitness activities and equipment use.

I acknowledge that I have either had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in the activity and use of the equipment without the approval of my physician and assume all responsibility for my participation in activities, and utilisation of equipment in my activities.

I acknowledge and understand that I may be photographed in session for use on the CrossFit Eora Facebook, Website, Google, Instagram or promotional material, and I release all images taken. If you do not agree please check below.
 No Photography Please

Finally, I acknowledge and agree that no warranties have been made to me by any representative of CrossFit Eora regarding the results I will or may achieve from any program conducted by CrossFit Eora. I understand that results are individual and may vary.

 YES I acknowledge.

I acknowledge that the above mentioned form is correct and true and any indicated issues have been cleared by a health professional as any guidance offered by CrossFit Eora is for general purposes only and is not to cure or treat any above mentioned items.

Digitally Signed:
Dated: