Well Built Humans Risk Waiver and Health Assessment

Name *

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Last

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Address

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Date of Birth *

Home Phone

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Photography/Video Release

Participants involved in any activities offered by Kingpin Kinetics, LLC dba Well Built Humans may be photographed or videotaped during training. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Kingpin Kinetics, LLC dba Well Built Humans website or in any editorial, promotional or advertising material published and/or published by Kingpin Kinetics, LLC dba Well Built Humans.

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Waiver and Release of Liability

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. These risks include, but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, my training partner, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above mentioned risks may result in serious injury or death to myself or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under direction of Kingpin Kinetics, LLC dba Well Built Humans.

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Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by Kingpin Kinetics, LLC dba Well Built Humans, I, the undersigned hereby release Kingpin Kinetics, LLC dba Well Built Humans, their principals, agents, employees and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect. If I am signing on behalf of a minor child, I also give full permission for any person connected with Kingpin Kinetics, LLC dba Well Built Humans to administer first-aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport to the child to a medical facility deemed necessary for the well-being of the child.

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Health Assessment

Regular physical activity is healthy, fun and safe if done properly. However, individuals should check with their physician prior to starting an exercise program. Please complete this form as accurately and completely as possible. This information will only be used to determine your individual training. All information will be kept confidential and not shared beyond our coaching staff.

Do you currently smoke? *

Do you currently drink? *

Are you currently taking any medications, prescription or non-prescription, that might impact your ability to safely perform physical activity? *

If you answered YES to any of the above, please elaborate:

Have you consulted your physician regarding increasing your physical activity and/or performing a fitness assessment? *

If NO, please consult your physician prior to increasing your physical activity and/or performing a fitness assessment.

What is your current fitness routine?

I certify that the above statements are true and correct to my knowledge. I understand that a doctor’s note may be requested. If a note is requested, I will not proceed with Kingpin Kinetics, LLC dba Well Built Humans until a note is given to the coaches.

Signature *

Date Signed *