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Session Start Date _________
Name: ___________________________________________________ Emergency Contact: ____________________________ Date: _________
Phone #: _______________________
Registration Fee ($150 non-member/$120 monthly member) $_________ Paid on _________ Cash/Check
Indicate any diseases or illness you have had or currently have ______ Heart Problems ______ Heart Attack ______ Chest Pain or Angina ______ Bypass or angioplasty ______ Abnormal Stress Test or Irregular Heart Beat ______ High Blood Pressure ______ High Cholesterol ______ Diabetes Mellitus, if yes, are you insulin dependent? ______ ______ Stroke ______ Impaired Circulation ______ Asthma or other breathing problems/shortness of breath ______ Fatigue ______ Low Blood Pressure ______ Hernia ______ Chronic Back Problems ______ Arthritis ______ Muscular Limitations ______ Epilepsy or Seizures ______ Knee Pain ______ Shoulder Pain ______ Any other diseases or chronic conditions not mentioned, if yes, please explain _________________________________________________________________________________ ______ Are you currently taking any medications? If yes, what type/reason __________________________________________________________________________________ __________________________________________________________________________________ ______ Are you pregnant? ______ Do you currently exercise? If yes, how many times per week? ___________
Studio Use Only: Starting Weight ________
Ending Weight: ____________
Prize Rewarded: ___________
Studio 356 Biggest Loser
WAIVER THIS IS YOUR RELEASE AND WAIVER OF LIABILITY (the “Release”). You individually release the Studio 356 LLC, its officers, directors, board members, employees, volunteers, agents, independent contractors, other participants and/or others acting on its behalf YOU AGREE THAT THIS RELEASE IS EFFECTIVE IMMEDIATELY. This is important to you so do not sign until you have had your questions answered. You provide this Release freely, and without duress under the following terms.
1. GENERAL RELEASE: I hereby agree for myself and my respective heirs, assigns and legal representatives, to indemnify, defend and hold Studio 356 LLC and its officers, directors, board members, employees, volunteers, agents, independent contractors and other participants (“Releasees”) in the program harmless from any and all claim and causes of action of any nature for any and all personal injury or illness, including death, which may occur to me or which may be aggravated during or by any activity during the course of the program in which I have decided to allow myself to engage. I further waive any and all claims or causes of action, which I may now or hereafter have against Releasees which may at any time arise as a result of any act or thing occurring in or arising out of my participation in the program. I further expressly understand and agree the foregoing indemnity, release and waiver is intended to be as broad and inclusive as permitted by the law of the State of Oregon and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full force and effect. 2. ASSUMPTION OF RISK: I, individually, expressly and specifically assume any and all risk of injury, illness, death, or property damage resulting from my STUDIO 356 LLC activities. YOU ASSUME THE RISKS: I, individually, understand that STUDIO 356 LLC activities are strenuous and dangerous and should be engaged in only by persons in good health. I understand that I should consult a physician before enrolling my-self in the STUDIO 356 LLC program. ONCE YOU SIGN, YOU ARE SAYING THAT YOU UNDERSTAND THE RISKS INVOLVED AND ACCEPT ALL OF THE RISKS. 3. MEDICAL RELEASE: I, individually, further hereby release STUDIO 356 LLC from any claim whatsoever which may arise as a result of any first aid, treatment, or services or assistance provided to me in connection with any injury that arises from activities with STUDIO 356 LLC. A) I take full responsibility for my welfare and safety on or at STUDIO 356 LLC activities. B) I hereby give permission for emergency medical treatment to be administered as deemed appropriate. 4. INSURANCE: I UNDERSTAND THAT I AM EXPECTED TO HAVE MY OWN HEALTH INSURANCE. I understand that the STUDIO 356 LLC is not responsible to cover injuries and losses that may befall me. 5. PHOTOGRAPHIC & VIDEO RELEASE: I consent to be photographed and/or video taped and to allow STUDIO 356 LLC’s use of any photos and/or videos of myself, with my permission, for promotion of this program. 6. ADDITIONAL RULES: I understand that I must be 18 years of age to participate in this program. I understand that having undergone gastric bypass surgery within the past four (4) months prohibits my participation. I confirm that I am not currently pregnant nor have I given birth within the past three (3) months. 7. WEIGH IN REQUIREMENTS: I understand that I MUST be present at the following Weigh Ins to remain eligible for Grand Prizes: March 3, March 31, April 28 and the final weigh in on May 12. If I miss any one of these weigh-ins, I will be disqualified to win a Grand Prize; however, I may still be eligible for weekly and/or additional prizes. 8. REGISTRATION & PAYMENT: I understand that payment must be received at time of registration to confirm my participation in this program.
HAVING READ, UNDERSTOOD, AND AGREED WITH THESE TERMS, I HAVE EXECUTED THIS RELEASE, TO BE EFFECTIVE IMMEDIATELY.
______________________________________________________ Applicant Signature If mailing, please remit registration and payment to: Studio 356 LLC 616 South Pike RD, Suite 202 Sarver, PA 16055 __________________ Date