CrossFit Meta Physical Activity Readiness Questionnaire & Waiver

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Name* This field is required.
First Name
Last Name
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E-mail* This field is required.
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Phone Number:* This field is required.
Area Code
Phone Number
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Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Birth Date:* This field is required.
Month
Day
Year
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Do you have an Instagram account?
YES
NO
PICK ONE
If YES, what is your username?
7
Do you have an Facebook account?If YES, please answer the sub-question.
YES
NO
PICK ONE
YES
NO
If YES, are you a member of the private Facebook CrossFit Meta group page?
8
How did you hear about CrossFit Meta?
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Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?If YES, Explain below:
YES
NO
PICK ONE
If YES, explain here.
10
Do you feel pain in your chest when you do physical activity?If YES, Explain below:
YES
NO
PICK ONE
If YES, explain here.
11
In the past month, have you had chest pain when you were not doing physical activity?If YES, Explain below:
YES
NO
PICK ONE
If YES, explain here.
12
Do you lose your balance because of dizziness or do you ever lose consciousness?If YES, Explain below:
YES
NO
PICK ONE
If YES, explain here.
13
Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?If YES, Explain below:
YES
NO
PICK ONE
If YES, explain here.
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Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?If YES, Explain below:
YES
NO
PICK ONE
If YES, explain here.
15
Do you know of any other reason why you should not do physical activity?If YES, Explain below:
YES
NO
PICK ONE
If YES, explain here.
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I am aware that there are significant risks involved in all aspects of physical training I understand that the reaction of the heart, lungs and vascular system to exercise cannot always be predicted with accuracy. I understand that there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart rate; chest, arm or leg discomfort; transient lightheadedness or fainting;and in rare instances, heart attack, stroke or even death. Excessive work can result (in rare cases) in exertional rhabdomyolysis. I should look for signs of excessive soreness, darkened urine, and pain in the kidney areas in the days following a particularly intense workout. While this type of injury is relatively rare, it can occur due to a number of factors,including (but not limited to) genetic predisposition or dehydration that may be beyond the control of my trainer. I Understand that the programs and classes offered by CrossFit META are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. 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. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s).* This field is required.Initial Below:
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I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in CrossFit META programs/classes and accept full responsibility for any injury or death that may result from participation in any activity, class or physical fitness program. I hereby certify that I know of no medical problems that would increase my risk of illness and injury as a result of participation in a fitness program designed by CrossFit META. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in CrossFit META programs/classes.* This field is required.Initial Below:
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By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive,physical exercise. By signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including, but not limited to, abnormal blood pressure,rhabdomyolysis, fainting, heart attack, or death. By signing this document, I assume all risk for my health and well-being and hold CrossFit META, as well as its owners, employees, and other authorized agents including independent contractors, harmless therefrom. I understand that questions about exercise procedure and recommendations are encouraged and welcome.* This field is required.Initial Below:
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Waiver and Release: I fully understand that my personal exercise program may be strenuous and I choose to participate voluntarily. I accept all responsibility for my health and any results, injury or mishaps that may affect my well being or health in any way. I waive any claims, demands, causes of action or any claims for relief whatsoever against,and release CrossFit META (as well as any of its owners, employees, or other authorized agents, including independent contractors and Southlands Church International) from any and all liability, claims and/or causes of action that I may have for injuries or other damages, arising out of participation in CrossFit META activities, including, but not limited to the personal training /nutritional programs and programs/classes.* This field is required.Initial Below:
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Photo/Video Release: I hereby grant CrossFit META permission to use my photograph/video image in any and all publications for CrossFit or CrossFit META, including web site entries, without payment or any other consideration in perpetuity. I hereby authorize CrossFit META to edit, alter, copy, exhibit, publish or distribute all photos and images. I Waive the right to inspect or approve the finished product, including written or electronic copy, wherein my photo appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph or video images. I hereby hold harmless and release and forever discharge CrossFit META from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of on behalf of my estate which may have or may have by reason of this authorization.* This field is required.Initial Below:
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Indemnification: I recognize that there is risk involved in the types of activities offered by CrossFit META. Therefore I accept financial responsibility for any injury that I may cause either to myself or to any other participant due to his/her negligence. Should the above-mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless CrossFit META, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by CrossFit META.* This field is required.Initial Below:
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I have fully read and fully understand the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.* This field is required.Initial Below:
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I have carefully read this Agreement and fully understand its contents. I am aware that this is a release and waiver of liability and sign it knowingly, voluntarily, and of my own free will.* This field is required.If under the age of 18, please have your Parent/Guardian sign below.
Clear
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If you are under 18 years of age, please have your Parent/Guardian Sign Below
ClearParent/Guardian Signature
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Leave this alone
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Thank you for filling out the online Physical Activity Readiness Questionnaire / Waiver!

-Coach Neil
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