UNBEATABLE MIND Event Application & Health Assessment Form

Event Health & Assessment Form

Select Your Event *

Full Name *

First Name Last Name

E-mail *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Gender *

Male Female

Age: *

Occupation: *

T Shirt Size *

Emergency Contact and/or Minors consent: *

Contact Information (Phone #) *

What other SEALFIT or Unbeatable Mind products/services have you experienced?

Please tell us about what you hope to get out of SEALFIT training, and how you have prepared your mind and bodies to succeed. List your stats for the benchmarks for your program: *

Please write 250 words or less

When was your last physical exam? *

Do you have any form of heart disease? *

Yes No

Do you experience shortness of breath or chest pains? *

Yes No

Do you currently have a workout regimen? *

Yes No

How many times per week?

Is there any reason that you know of that you should not participate in an exercise program? *

Yes No

Have you ever had anything implanted or any organ removed from your body? *

Yes No

If yes, please list the procedure and date.

If you answered yes to any of these questions please add details here.

High Blood Pressure? *

Yes No

Cigarette Smoking? *

Yes No

Diabetes? *

Yes No

Family history of heart disease? *

Yes No

Are you taking any medications? *

Yes No

If you answered yes to any of these questions please add details here.

Knees? *

Yes No

Lower Back? *

Yes No

Neck / Shoulders? *

Yes No

Hip / Pelvis? *

Yes No

Other? *

Yes No

If you answered yes to any of these questions please add details here.

Please list any special dietary considerations you may have.

Informed Consent

I desire and agree to participate in one or more of the following: physical fitness assessments, classes, camps, workouts, personal training sessions and programs; nutritional programs; informational classes; group and individual workouts; coaching, events; and/or assistance or instruction of any kind or any other activities (collectively “Activities”) provided through, sponsored or held by UNBEATABLE, LLC a California limited-liability company (“UNBEATABLE”) and/or UNBEATABLE affiliates including but not limited to SEALFIT INC.(“SEALFIT”), US CrossFit (“UCF”), and/or any other affiliate, subsidiary, or partnership, or agent of or to UNBEATABLE (collectively, and together with the owners, officers, directors, employees, contractors, agents and the City of Encinitas of any of the foregoing entities and each of their heirs or assigns, referred to herein as the “Released Parties”).

Prior to participating in any of the Activities, I have been informed that the Activities are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. I understand that the Activities are not without varying degrees of risk, which may include, but are not limited to the following: muscle soreness, minor aches and pains, tiredness, stiff joints and muscles, tearing or straining of muscles, ligaments, tissue or bone tearing or breakage; serious bodily injury or death, including due to the negligence on the part of me, other participants, the Released Parties, or third parties; and or due to improper use of or failure of equipment. I understand that the reaction of the heart, lungs and vascular system to the Activities cannot always be predicted with accuracy. I understand that there is a risk of certain abnormal changes occurring during or following the Activities, which may include, but are not limited to, abnormalities of blood pressure or heart rate; chest arm or leg discomfort; transient light-headedness or fainting; and in rare instances, heart attack, stroke or even death. Excessive physical exertion during the Activities can result in exertional rhabdomyolysis. I have been advised to look for signs of excessive soreness, darkened urine, and pain in the kidney areas in the days following my participation in the Activities. While this type of injury is relatively rare, it can occur due to several factors, including, but not limited to, genetic predisposition or dehydration, that may be beyond the control of the Released Parties. The above are not the only symptoms of an injury or condition. I am responsible to seek medical advice and treatment for any injury, symptom or concern I may have regarding my health.

Confirm *

I have read and understood this section

Statement of medical condition.

I understand and acknowledge that the Activities offered through the Released Parties are designed to be difficult for very fit persons, including elite athletes, competitive athletes, and combat ready troops. As an inducement to the Released Parties to allow me to participate in the Activities, I do hereby state and certify ALL of the following: i) I receive periodic medical check-ups (at least once a year), ii) I have had a physical examination from a competent physician within the past 12 months; iii) I have been advised to consult with my physician prior to my participation in the Activities regarding my fitness for participation in the Activities, and iv) that I have no cardiovascular or other concerns, problems, or illness that might keep me from participating in the Activities, including, but not limited to, heart problems, lung problems, circulatory problems, diabetes, high blood pressure, low blood pressure, hardening of the arteries, shortness of breath, chest pains, arrhythmia, heart palpitations, arterial dysfunction, circulatory disorders, or other conditions that would raise concern in the mind of a reasonable person. I have no knowledge of any other medical problem or condition or issue that might increase my risk of illness and injury as a result of my participation in the Activities. The Released Parties have fully and carefully informed me that I may experience adverse physical changes including injury or death even in the absence of any prior medical problem, condition or issue, and I fully understand this to be the case. I again agree to assume any and all risk associated with my participation in the Activities.

Confirm *

I have read and understood this section

Medical & Psychotherapy Disclosure.

The Released Parties do not provide medical treatment or advice, psychological counseling or psychotherapy, and no person engaged by the Released Parties is authorized to act on behalf of the Released Parties in the capacity of a licensed therapist or medical doctor in the State of California. The Released Parties do not diagnose or treat medical conditions or mental disorders. Information conveyed within the Activities is not intended to be, and is not, a substitute for psychotherapy or medical advice and treatment and are not therapeutic or medical in nature. I understand that any value I obtain from the Activities, I obtain via my own free will and participation. I hereby forever release UNBEATABLE and/or SEALFIT along with the other Released Parties from all liability from any adverse or negative reactions or effects that my participation in the Activities may have on me.

Confirm *

I have read and understood this section

Assumption of All Risks.

For, and in consideration of, as an inducement for being allowed to participate in the Activities, I do hereby intentionally, willingly, and voluntarily assume full responsibility for my health and any and all risks of injury or adverse reaction, including serious bodily injury or death as stated above to which I may be exposed as a result of my participation in the Activities. I accept full and complete responsibility for any injury or death, including expressly, any injury or death which may result from my own negligence or the negligence or willful acts or omissions of other participants, the Released Parties or any third party. I agree to hold the Released Parties harmless from any and all claims, including attorneys’ fees or damage to my personal property that may occur as a result of participation in the Activities, including travel to, from and during the Activity. If the Released Parties incur any of these types of expenses, I agree to reimburse them. Should I require medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry health insurance.

Agreement to Follow Directions. I agree to follow the rules for the Activities provided to me and to follow directions given to me by the leaders of the Activities.

Independent Contractors. I acknowledge that the Released Parties have no control over and assume no responsibility for the actions of any independent contractors providing any services for the Activities.

Confirm *

I have read and understood this section

Waiver and Release.

For in consideration of, and as an inducement for being allowed to participate in the Activities, and in recognition of the above-mentioned risks and hazards including, but not limited to the risk of serious bodily injury or death, I do hereby forever intentionally, willingly, and voluntarily release, waive, remise, discharge and hold harmless the Released Parties, from any and all liability, losses, expenses, costs, attorneys’ fees, damages, claims and causes of action arising directly or indirectly out of my participation in the Activities, whether such claims be emotional, mental, psychological, physical, financial or otherwise. I hereby, to the maximum extent allowed by law, hold harmless and release and forever discharge the Released Parties 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. By signing this document, I intend to forever waive my right to maintain any lawsuit or action against the Released Parties based on any claim of personal injury or death or property loss or damage. I have had sufficient opportunity to read and understand this Agreement and consult with legal counsel or have voluntarily waived my right to do so. I knowingly and voluntarily agree to be bound by all terms and conditions set forth herein

Confirm *

I have read and understood this section

Confirm *

I have read and understood this section

Indemnification.

As a further inducement to the Released Parties to permit me to participate in the Activities, I accept financial responsibility for any injury I may cause either to myself or to any other participant or third party, whether due to the negligence or willful misconduct of me, third parties, or anyone acting on their behalf. Should the Released Parties be required to incur attorneys’ fees or other costs to enforce this Agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless the Released Parties 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.

Confirm *

I have read and understood this section

Arbitration

Any controversy or claim arising out of or relating to this Agreement or the performance thereunder, including without limitation any claim related to illness, injury or death shall be settled by binding arbitration in San Diego County, California, in accordance with the rules of JAMS then existing. The California Evidence Code shall apply to any arbitration proceeding held pursuant to this Agreement.

I HAVE CAREFULLY READ, FULLY UNDERSTAND AND AGREE TO EACH AND EVERY TERM, CONDITION, AND PROVISION CONTAINED IN THIS “AGREEMENT”. I UNDERSTAND THAT MY AGREEMENT IS AN INDUCEMENT, WHICH SEALFIT/US CROSSFIT/UNBEATABLE RELIES UPON AND WITHOUT WHICH, SEALFIT/US CROSSFIT/UNBEATABLE WOULD NOT ALLOW ME TO PARTICIPATE IN THE ACTIVITIES. IF I DO NOT AGREE WITH THE TERMS, CONDITIONS, PROVISIONS OR THIS AREEMENT, I WILL NOT PARTICIPATE IN ANY OF THE ACTIVITIES. I UNDERSTAND THAT BY SIGNING THIS AGREEMENT, I AM WAIVING VALUABLE LEGAL RIGHTS. I UNDERSTAND THAT THIS AGREEMENT IS WRITTEN TO BE AS BROAD AND INCLUSIVE AS LEGALLY PERMITTED BY THE STATE OF CALIFORNIA. I AGREE THAT IF ANY PORTION IS HELD INVALID OR UNENFORCEABLE, I WILL CONTINUE TO BE BOUND BY THE REMAINING TERMS. I AM 18 YEARS, OLDER, OR RESPONSIBLE FOR A MINOR. I HAVE READ THIS AGREEMENT, AND I AM SIGNING IT FREELY. I AGREE TO BE BOUND BY THE TERMS OF THIS AGREEMENT.

Confirm *

I have read and understood this section

Upload Your Photo

Please include a photo of your face.

I hereby consent and authorize SEALFIT to take photographs or motion pictures of me; or to produce videotapes, audiotapes, closed circuit television programs, web casts, or other types of media productions that capture my name, voice, and/or image (any of the foregoing types of media are called the "Materials" in this Consent and Release form).

I authorize SEALFIT to copyright the Materials, and I authorize SEALFIT to use, reuse, copy, publish, display, exhibit, reproduce, license to third party, and distribute the Materials in any educational or promotional materials or other forms of media, which may include, but are not limited to, catalogs, articles, magazines, brochures, websites or publications, electronic or otherwise, without notifying me.

I also agree that SEALFIT may identify me by name, and such other identifying information as class year, graduation date, hometown, etc. unless otherwsie requested

Confirm *

I have read and understood this section I do not wish to share my photo

Important Links

Cancellation Policy

Signature of Candidate or Parent/Guardian

use your mouse to sign on line within box Clear

Health Assessment

Do any of the following pertain to you?

Do you have problems in any of the following areas?

Dietary Information

ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNIFICATION AGREEMENT

PHOTOGRAPH/MEDIA CONSENT AND RELEASE