Fitness Quest 10 Liability Form

 

Client Profile

Last Name___________________________

First Name ___________________

Street Address ________________________________________________

City/State ________________________________ Zip_________________

Work Phone _____________________

Home Phone _________________

Date of Birth __________________  Height _________

Weight ________

Email Address:___________________________________

Please note any surgeries or injuries (past or present)

Foot

Left____________________ Right____________________

Ankle

Left____________________ Right____________________

Knee

Left____________________ Right____________________

Hip

Left____________________ Right____________________

Shoulder

Left____________________ Right____________________

Elbow

Left____________________ Right____________________

Wrist

Left____________________ Right____________________

Hand

Left____________________ Right____________________

Neck

Left____________________ Right____________________

Back

Left____________________ Right____________________

LIABILITY WAIVER

The undersigned recognizes that the use of Fitness Quest 10’s services involve an inherent risk of physical injury including that caused by the negligence of the undersigned, Todd Durkin, Fitness Quest 10, or contractors and employees of Fitness Quest 10.  The undersigned hereby agrees to assume the risk of injury in its entirety regardless of the cause.  Todd Durkin, Fitness Quest 10, and all contractors and employees of Fitness Quest 10 shall not be liable for injuries or damages to the undersigned, or the property of the undersigned, or by subject to any claim, demand, injury, death, or damages whatever, including, without limitation, those damages resulting from acts of active or passive negligence on the part of Todd Durkin, Fitness Quest 10, and all contractors and employees of Fitness Quest 10 for all such claims, demands, injuries, death, damages, actions, or causes of action.  It is specifically agreed that Todd Durkin, Fitness Quest 10, and all contractors and employees of Fitness Quest 10 shall not be responsible or liable to the undersigned for articles lost or stolen in connection with Todd Durkin, Fitness Quest 10, or contractors and employees of Fitness Quest 10’s service.

Printed Name: _______________________________________________

Signature: ___________________________________________________

Date: _______________________________________________________

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