Crossfit Central

Name (last) __________________ (First)_________________________(MI)_________

Home Address (street)_______________________(city)____________(state)_________

(Zip)_____________Phone(Home)_____________(Work)__________Ext___________

Cell___________________________DOB____/___/______Weight_____Sex:_M__F__

Emergency Contact____________________ Phone______________________________
Email______________________________
Section I: RISK ASSESSMENT

Have you ever had any form of heart disease? YES NO
Have you ever experienced shortness of breath or chest pain? YES NO

Date of last full physical ___/____/____

Do you have or do any of the following pertain?
Please explain ot the best of your ability

High Blood Pressure Yes No Levels: _____________
High Cholesterol Level Yes No Levels: _____________
Cigarette Smoking Yes No How many per day? ___
Smoked in Past Yes No How Long? __________
Diabetes Yes No insulin dependent? ___
Family history of heart disease Yes No Who/Age? ___________
Are you Active Yes No
Are you currently taking any medication? Yes NO Explain: ___________________

Do you have any problems in the following areas?
Please explain to the best of your ability.
Knee Yes No Explain___________________
Low Back Yes No Explain_____________________Neck/Shoulders Yes No Explain_____________________
Hips/Pelvis Yes No Explain_____________________
Flexibility Yes NO Explain_____________________
Any Other Yes No Explain_____________________

Waiver and ReleaseIn consideration of the foregoing, 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 The Event, its Primary Sponsor and its affiliates, their agents, employees, officers, directors, successors and assigns, the Event Management Company, Inc., the City, the Park District, 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 my physical condition has been verified by a licensed medical doctor. 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.

X_______________________