Health Questionnaire

Name *
Name
Date of Birth
Date of Birth
Have you been exercising consistently for the past 3 months?
LIABILITY WAIVER/RELEASE: I understand and acknowledge that weight, cardiovascular and aerobic training, and related activities can be hazardous and can result in injuries. In consideration of gaining membership or being allowed to participate in the activities and programs of Reuben Brooks fitness, and to use its nutrition and workout advice, in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge Reuben Brooks and its officers, agents, employees, representatives, executors, members and directors, and all others (hereinafter sometimes collectively referred to as the Released Parties) from any responsibility or liability for injuries or damages (including but not limited to physical injury, emotional injury, property damages, economic damages, non-economic damages and punitive damages) resulting from my participation in any activities or nutrition advice from the above-mentioned website, or arising out of my participation in any activities or nutrition advice from, said website. I do also hereby release the Released Parties and any others acting on their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission (including passive negligence, active negligence or gross negligence) of the Released Parties or others acting on their behalf, or in any way arising out of or connected with my participation in any activity at, or in any way connected with the Released Parties. This Waiver and Release of all liability includes, without limitation, a release of the Released Parties and any others acting on their behalf, from any injuries which may occur as a result of (a) my use of any exercise (b) my use of any nutrition advice, (c) the Released Parties’ improper suggestion of nutrition or exercise, (d) the Released Parties' negligent instruction or supervision, (e) the Released Parties' negligent hiring or negligent retention of any employees, (f) any claim for loss of consortium, (g) my tripping, slipping or falling, or (h) any claims relating to the availability or administration of first aid, emergency treatment or any other services which are alleged to have been negligently rendered or failed to be rendered by those mentioned above or anyone acting on their behalf, emergency personnel or Good Samaritans, including any allegation that the Released Parties have prevented a Good Samaritan from rendering aid. Wherever used in this document, the terms "I, my, me, myself, you, your, yourself" shall refer to the person applying for membership. Where a parent or guardian completes and signs this Agreement on behalf of a child or ward, those terms shall refer to the parent or guardian individually, and also shall refer to the parent/guardian as the guardian of the minor child/ward.
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