CLIENT PROFILE QUESTIONNAIRE
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NAME:
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DATE:
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CELL NO.
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EMAIL:
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ADDRESS:
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CITY:
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Gender:
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Birth date:
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Health & Medical Conditions Check any that apply or describe any other(s).
I, AGREE TO ALLOW THE ENDORPHIN EFFECT, INC. STAFF, TO DESIGN A PROGRAM FOR ME TO ENHANCE MY HEALTH & FITNESS GOALS. I WILL FOLLOW THAT PROGRAM TO THE BEST OF MY ABILITY AND I WILL NOT HOLD THE ENDORPHIN EFFECT, INC. OR ANY ONE RELATED PERSONS OR PARTIES PERSONALLY LIABLE FOR ANY PROBLEMS, ILLNESSES OR INJURIES THAT MIGHT OCCUR DUE TO A SUDDEN CHANGE IN MY EXERCISE OR EATING HABITS. THIS WEIGHT MANAGEMENT PROGRAM DOES NOT REPLACE THE EXPERT ADVICE OR MEDICAL TREATMENT OF MY OWN PRIVATE DOCTOR I HAVE GIVEN THE ENDORPHIN EFFECT, INC. ALL NECESSARY INFORMATION ABOUT MYSELF TO PREVENT ANY POSSIBLE COMPLICATIONS. I UNDERSTAND THAT THIS MEMBERSHIP IS NOT ASSIGNABLE OR TRANSFERABLE. SHOULD I CANCEL MY MEMBERSHIP, I UNDERSTAND THAT ANY PAYMENTS ARE NON-REFUNDABLE.
Signature:
Date:
WAIVER AND RELEASE OF LIABILITY
In consideration of the risk of injury while participating in all activities, including but not limited to yoga, spin, fitness classes, personal training, boxing, kick boxing, various martial art disciplines, massage, any therapy, functional training and/or gym training, (hereinafter collectively and/or individually referred to as the "Activity" or “Activities”), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge THE ENDORPHIN EFFECT, INC., located at 891 S. Rte. 59, Bartlett, Illinois 60103, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity.
I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITIES AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I REPRESENT AND WARRANT THAT I AM IN THE APPROPRIATE PHYSICAL CONDITION FOR THE PHYSICAL ACTIVITES IN WHICH I WILL PARTICIPATE AND THAT IF I AM UNSURE IF I AM IN THE APPROPRIATE PHYSICAL CONDITION FOR THE PHYSICAL ACTIVITIES IN WHICH I WOULD LIKE TO PARTICIPATE, I WARRANT AND REPRESENT THAT I WILL CONSULT MY PERSONAL PHYSICIAN PRIOR TO MY PARTICIPATION IN ANY PHYSICAL ACTIVITY. I AM AWARE OF THE RISKS ASSOCIATED WITH TRAVELING TO AND FROM AS WELL AS PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO, PHYSICAL CONTACT WITH OTHER INDVIDUALS AND/OR HEAVY BAGS AND/OR OTHER EQUIPMENT, PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL, OR THE CONDITION OF THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY, INCLUDING TRAVEL TO, FROM AND DURING THIS ACTIVITY.
I ACKNOWLEDGE THAT THESE ACTIVITIES MAY INVOLVE A TEST OF A PERSON'S PHYSICAL AND MENTAL LIMITS AND MAY CARRY WITH IT THE POTENTIAL FOR DEATH, SERIOUS INJURY, AND PROPERTY LOSS. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic and actions of others, including but not limited to, participants, volunteers, spectators, coaches, event officials and event monitors, and/or producers of the event.
I agree to indemnify and hold harmless THE ENDORPHIN EFFECT, INC. against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If THE ENDORPHIN EFFECT, INC. incurs any of these types of expenses, I agree to reimburse THE ENDORPHIN EFFECT, INC. I acknowledge that it is my responsibility to cover any medical bills that I may incur and to cover myself with any medical insurance that I may deem appropriate and I further acknowledge that I will not and cannot make any claim for medical coverage resulting from any injury or death incurred by me at THE ENDORPHIN EFFECT facility.
I acknowledge that THE ENDORPHIN EFFECT, INC. and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of THE ENDORPHIN EFFECT, INC. THE ENDORPHIN EFFECT, INC., shall not be liable for any loss or theft of my personal property.
PHOTOGRAPHIC RELEASE. I GRANT AND CONVEY UNTO THE ENDORPHIN EFFECT, INC. ALL RIGHTS, TITLE, AND INTEREST IN ANY AND ALL PHOTOGRAPHIC IMAGES AND VIDEO, DIGITAL MEDIA OR AUDIO RECORDINGS MADE BY THE ENDORPHIN EFFECT, INC. IN ANY AND ALL OF ITS PUBLICATIONS, INCLUDING WEB-BASED PUBLICATIONS, DURING MY TIME AT THE ENDORPHIN EFFECT, INC. FACILITY AND/OR AT ANY EVENT OFF-SITE THAT IS SPONSORED/ORGANIZED/RUN BY THE ENDORPHIN EFFECT, INC. INCLUDING, BUT NOT LIMITED TO, ANY ROYALTIES, PROCEEDS, COMPENSATION OR OTHER BENEFITTS DERIVED FROM SUCH PHOTOGRAPHS OR RECORDINGS. I UNDERSTAND AND AGREE THAT ALL PHOTOS, IMAGES, VIDEO, DIGITAL MEDIA OR AUDIO RECORDINGS WILL BECOME THE PROPERTY OF THE ENDOPRHIN EFFECT, INC. I HEREBY IRREOVOCABLY AUTHORIZE THE ENDOPRHIN EFFECT, INC. TO EDIT, ALTER, COPY, EXHIBIT, PUBLISH OR DISTRIBUTE THESE PHOTOS FOR ANY LAWFUL PURPOSE.
I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE THE ENDORPHIN EFFECT, INC. AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST THE ENDORPHIN EFFECT, INC. FOR PERSONAL INJURY OR PROPERTY DAMAGE.
To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of THE ENDORPHIN EFFECT, INC., its agents, and employees.
In the event that I should require medical care or 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 and am obligated to carry my own health insurance.
In the event that any damage to equipment or facilities occurs as a result of my or my family's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness.
This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both the Participant, , and THE ENDORPHIN EFFECT, INC. agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.
I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
Minor Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Minor Birth date: <CHILDBIRTHDAY>
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date: