Event Application & Health Assessment

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Gender*

Male
Female

Age*

Please enter a number greater than or equal to 16.

Occupation*

Upload a photo of yourself*

Max. file size: 100 MB.

Emergency Contact Name*

Emergency Contact Phone Number*

Health Assessment

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.

Do any of the following pertain to you?

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.

Do you have problems in any of the following areas?

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.

Statement of Assumption of Risk, Release and Indemnification & Non Disclosure

I agree to participate in one or more physical fitness programs, classes, workouts or events sponsored or held by Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies which may include but does not require, and is not limited to, one or more of the following: initial assessment, introductory training, personal training and/or coaching, Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies, and/or physical fitness training, and/or assistance or instruction of any kind, by CrossFit and/or any affiliate, subsidiary or partnership of Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies. Prior to participating, Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies have made me fully aware that the fitness programs/classes which they offer and in which I desire to participate are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. I recognize and understand that the programs/classes and exercises undertaken therein 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 of muscles, ligament, muscle, tissue or bone tearing or breakage, serious and/or life- threatening injuries to the musculoskeletal and/or cardio respiratory systems, serious bodily injury or death.*

I have read and understood this section

Statement of medical condition. I realize that Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies offer training programs that are difficult for very fit persons, including elite athletes, competitive athletes, and combat-ready troops. Knowing this to be the case, I do hereby state and certify that I receive periodic medical check-ups at least once a year, that I have had a physical examination from a competent physician within the past 12 months, and that I have no cardiovascular or other concerns, problems or illnesses that might keep me from participating in a Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies training program, such as (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 condition that would raise concern in the mind of a reasonable person. I have no knowledge of any other medical problem or condition or problem that might increase my risk of illness and injury as a result of participation in such a program. Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies has fully and carefully informed me that I may experience adverse physical changes during and/or after exercise, such as joint or muscular aches and/or pain, swelling, abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and in very rare instances, heart attack or even death, and again, I fully understand this to be the case. With my full understanding of this information, I again agree to assume any and all risk associated with my participation in Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies fitness programs/classes.*

I have read and understood this section

Assumption of All Risks. For and in consideration of being allowed to participate, I do hereby intentionally, willingly and voluntarily assume full responsibility for any and all risks of injury, including serious bodily injury or death, as stated above, to which I may be exposed as a result of my participation in Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies physical fitness programs, classes, workouts or events. I accept full and complete responsibility for any injury or death, including expressly any injury or death that which results from my own negligence.*

I have read and understood this section

Release. For and in consideration of being allowed to participate, and in recognition of the above-mentioned risks and hazards, I do hereby intentionally, willingly and voluntarily release, waive, remise and discharge Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies and its agents, officers, principles, and employees, and each of their heirs and assigns from any and all claims and causes of action, known or unknown, including any liability, claim, demand, action or right of action arising or out of my participation in the above-referenced activities.*

I have read and understood this section

Indemnification: I recognize that there is risk involved in the types of activities offered by Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies. Therefore I accept financial responsibility for any injury that I or the participant may cause either to him/herself 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 Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies, 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 Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies.*

I have read and understood this section

Non-Disclosure: "Confidential Information" will mean any and all tangible and intangible information, whether written, oral or in any other medium, originated by or uniquely within the knowledge of Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies and not generally available to third parties. Confidential Information may include, without limitation, any and all trade secrets, financial information, know-how, designs, methodologies, processes, manuals, marketing information, price lists, customer lists, supplier lists, employee information, computer programs, and systems designs.*

The Receiving Party (Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies, partners or trainees) will keep the Confidential Information in strict confidence, using the same standard of care as it does with respect to its own Confidential Information, but in no event less than a reasonable degree of care. Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies will permit only those of its employees, agents, representatives, attorneys, consultants, and financial advisors access to the Confidential Information who have a bona fide need to know in connection with the Permitted Purpose, provided that all such persons must be required to comply with the terms of this Agreement with respect to such Confidential Information.

Confidential Information will not include any information that the Receiving Party can demonstrate:

• was publicly know at the time of disclosure by the Disclosing Party, or becomes publicly known through no fault of the Receiving Party;

• was rightfully received from a third party without a duty of confidentiality;

• is already known to the Receiving Party at the time of receiving such Confidential Information or is independently developed by the Receiving Party without reference to the Confidential Information;

• is permitted to be disclosed by written consent of the Disclosing Party; or;

• is required to be disclosed by an order of a governmental agency, legislative body or court of competent jurisdiction; provided that the Receiving Party provides the Disclosing Part with prompt notice of such requirement, so that the Disclosing Party may seek an appropriate protective order and/or waive compliance with this Agreement.

• Disclosure by the Disclosing Party of Confidential Information does not constitute a warranty that the Confidential Information is accurate, complete, or adequate for the purposes contemplated by the Receiving Party. Confidential Information is provided “AS IS”.

I have read and understood this section

Initials*

I have read the foregoing document. I understand it. I have been given a full and complete opportunity to ask any and all questions regarding it. I understand that by signing it, I am waiving and otherwise affecting my valuable legal rights. It is my intention to do so.*

I have read and understood this section

Photograph/Media Consent and Release

I hereby consent and authorize Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies 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 Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies to copyright the Materials, and I authorize Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies 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 Human Wellness Solutions LLC, Ben Greenfield and any affiliated companies may identify me by name, and such other identifying information as class year, graduation date, hometown, etc. unless otherwsie requested.

I have read and understood this section

Signature of Candidate*

Greenfield Fitness Systems

Performance, Fat Loss, Nutrition Solutions from Ben Greenfield

Health Assessment

Do any of the following pertain to you?

Do you have problems in any of the following areas?

Statement of Assumption of Risk, Release and Indemnification & Non Disclosure

Photograph/Media Consent and Release

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