CROSSFIT LEWES LLC

CLIENT INFORMATION FORM/WAIVER DATE: ________________

Name (Last) ______________________________ (First) _________________________________________

Home Address/City/State/Zip: _______________________________________________________________

Home Phone #: _________________________________ Mobile #: ________________________________

Email Address: ___________________________________________________________________________

DOB: _mo____________ / _day_______________ / __yr________________

Weight: _________________ Gender (please circle one): Male Female

Emergency Contact (Name/Relation) ______________________________________________________

Emergency Contact (Home & Cell Numbers): (H)_____________________(M)______________________

Do any of the following pertain to you:

High Blood Pressure Yes No Levels: ________________________

High Cholesterol Yes No Levels: ________________________

Cigarette Smoking Yes No # Per Day: ________________________

Smoked in Past Yes No How Long: ________________________

Diabetes Yes No Insulin: Yes No

Family History of Heart Disease Yes No Who/Age ________________________

Do you currently exercise Yes No # Times Week: ________________________

Are you currently on medication Yes No Type(s) ________________________

________________________

Please specify any allergies / allergies to medications: _____________________________________________________

Do you have problems in any of these areas:

Knee(s) Yes No

Lower Back/Neck/Shoulders Yes No

Hips/Pelvis Yes No

Other (please explain) Yes No ___________________________________________

How did you hear about CrossFit Lewes? _________________________________________________________________________

In consideration of the forgoing, I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns, waive and release any and all rights, claims and courses of action I have or may have against CrossFit Lewes or anyone associated with the entity, it’s Primary Sponsor and it’s affiliates, their agents, employees, officers, directors, successors and assigns, the Event Management Company, the City, The Parks Districts, and any and all sponsors, their representatives and successors, that may arise as a result of my participation in the event and any pre-and post-event activities. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event, and a licensed medical doctor has verified my physical condition. Further, I hereby grant full permission to any and all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose including commercial advertising.

Signed: ____________________________________ Print Name: _____________________________________________

Office Use: CrossFit Lewes Staff member: __________________________ date:_____________________

CFL STAFF ACCEPTING THIS FORM MUST VERIFY COMPLETENESS OF INFORMATION &SIGNATURE OF CLIENT