CFBN CrossFit Kids • 401 Bronco Dr Unit D • Bloomington, IL 61704

Welcome to CFBN CrossFit Kids Summer Camp 2015

General Registration Form Child’s Name__________________________________ Age______ DOB__________________

Address: ______________________________________________________________________

City, State, Zip:_________________________________________________________________

Name(s) of Parent(s)/Guardian(s):__________________________________________________

Phone: h)_______________________________c)_____________________________________

Email Address: _________________________________________________________________

How did you find out about us? ____________________________________________________

Please provide two emergency contacts and their phone numbers:

Emergency Contact Name/Relationship: _____________________________________________

Phone: _______________________________________________________________________

Emergency Contact Name/Relationship: _____________________________________________

Phone :_______________________________________________________________________

Date of last physical exam: ______________________________________________________

Doctor Name and Phone: _______________________________________________________

Classes/Fees: 2015 CrossFit Kids Summer Camp

(Please Check One)

June 16th-July 30th (Camp will meet on Tuesdays and Thursdays) – 7 weeks (14 sessions)

□ Ages 3 - 6 9:15 am- 9:45 am - $175

□ Ages 7 – 10 10:00 am – 10:45 am - $245

* Price Includes T-shirt – Please select your child’s T-shirt size from the choices below

□Extra Small (2-4) □Small (6-8) □Medium (8-10) □Large (10-12)

□Extra Large(14-16) □Adult Small □Adult Medium □Adult Large

Physical Activity

What is your child’s current activity level? ____________________________________________

Does your child participate in team sports? If yes, which ones? __________________________

_____________________________________________________________________________

Does your child exercise regularly? ______ Approximate number of minutes/day of moderate

physical activity (equal to a one mile run.) ________ Approximate number of days/week at this

level: ___________

General Health/ Physical Activity Readiness Questionnaire Please indicate if your child has ever been diagnosed with, has a history of, or a currently has of any of the following: ADD/ADHD □Yes □No Autism or Aspergers □Yes □No Head Trauma/Concussion(s)* □Yes □No Epilepsy* □Yes □No Allergies □Yes □No Asthma * □Yes □No Heart Condition * □Yes □No High Blood Pressure* □Yes □No Shortness of Breath* □Yes □No Severe Dizziness/ Feels Faint* □Yes □No Irregular Heart Beat/Arrhythmia* □Yes □No Chest Pains during or after exercise* □Yes □No Broken Bone within the last 6 months* □Yes □No Bone or Joint Problems aggravated by exercise* □Yes □No Back Pain* □Yes □No Diabetes type 1 or type 2* □Yes □No Autoimmune Disease* □Yes □No Recent Surgery * □Yes □No

*If you answered “yes” to any of the above marked with a(*), it is important to note that there may be restrictions on your child’s ability to participate an exercise program. If you are unsure of any of the information you have provided, we strongly advise that you consult with your child’s doctor before allowing your child to begin any exercise program. If you answered “yes” to any of the above, please explain. Also, please list any other health concerns/conditions, including psychological (bi-polar disorder, OCD, etc.) your child may have, even if you think they may not be important, or are not addressed in this questionnaire. _____________________________________________________________________________

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Does your child take any prescription or over-the-counter medications? If so, please list and the condition for which they are taken: _________________________________________________ _____________________________________________________________________________

Does your child need a rescue inhaler? _____________ If so, do you give your permission for CFBN trainers to help administer the use of a rescue inhaler if necessary? _____________________________________________________________________________

Do you know of any reason your child should not participate in physical activity? If so, please indicate: ______________________________________________________________________ If your child’s health status changes, you are required to tell your fitness professional. (CFBN Trainer.) Ask whether this change in health status requires an adjustment to their physical activity plan.

Release & Waiver of Liability & Indemnity Agreement Photo/Video Release & Medical Authorization

I ___________________(print Guardian’s name), HEREBY ACKNOWLEDGE that I have voluntarily permitted __________________(print Participant’s name) to participate in classes and programs and/or other activities at, by, and under the direction of Functional Performance Institute, LLC doing business as CrossFit Bloomington Normal (CFBN). I understand that the training at CFBN may include, but may not be limited to, resistance training and aerobic or cardiovascular exercise, bodyweight exercises, and exercises involving, among other things, the use of dumbbells, barbells, kettlebells, and medicine balls. I AM AWARE THAT THESE ACTIVITES AND ALL OTHER PROGRAMS AND ACTIVITIES AT, BY, AND UNDER THE DIRECTION OF CROSSFIT EAST INVOLVE RISKS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH. I AM VOLUNTARILY PERMITTING PARTICIPANT TO PARTCIPATE IN THESE ACTIVITIES WITH KNOWLEDGE OF THESE RISKS AND DANGERS AND HEREBY AGREE TO ACCEPT ANY AND ALL RISK OF INJURY TO PARTICIPANT THAT MAY RESULT THEREFROM. Further, in consideration and exchange for Participant being permitted by CFBN to participate in these activities and/or use its facilities, I HEREBY AGREE THAT I WILL NOT MAKE A CLAIM AGAINST OR SUE, ON BEHALF OF MYSELF OR PARTICIPANT, CFBN or any of its principals, members, managers, independent contractors, trainers, employees or agents, for injury or damage resulting from the equipment or facilities of CFBN, or from the negligence or other acts or omissions, howsoever caused, of any independent contractor, trainer, employee, or agent of CFBN, or of any other participant or member of CFBN, during Participant’s participation in any activity at, by, or under the direction of CFBN. This agreement to not sue includes a release and waiver, to the fullest extent permitted under the law, and on behalf of myself and Participant, in favor of the parties identified above, of any and all claims, demands, damages, rights, and causes of action, present or future, arising out of or connected with Participant’s activities at, by, or under the direction of CFBN. I further agree to defend, indemnify, and hold harmless CFBN and its principals, members, managers, independent contractors, trainers, employees and agents from liability or alleged liability for the injury or death of any person or damage to any property that may result from my or the Participant’s negligent or intentional acts or omissions occurring at, by, or under the direction CFBN. I declare that I have completed the enclosed medical questionnaire on behalf of Participant, as required by CFBN and that I declare and maintain that Participant is physically able to participate in the physical activities set forth above. Furthermore, I declare that CFBN has advised me to obtain a medical clearance for Participant in the event that I have answered “yes” to any of the medical history questions, or if I am unsure of Participant’s physical health. This waiver and consent shall be binding upon Guardian’s and Participant’s heirs, executors, administrators, and/or assigns. If any part, portion, or provision of this agreement is held void or invalid for any reason, I agree that the remainder of the agreement shall remain in full force and legal effect. Photo/Video Release: I hereby give permission for images of Participant, captured during regular and special activities through video, camera, and digital camera to be used solely for the purposes of CFBN and/or CrossFit Kids promotional material, publications, and web site, and waive any rights of compensation or ownership thereto. Last names of minors will not be given or posted on the web site. Medical Authorization: I hereby authorize CFBN to seek medical treatment for Participant if necessary. Treatment may include standard first aid, CPR, and/or medical transport of Participant to a doctor, hospital or other health care facility and to act in my place to obtain medical or hospital treatment. Guardian Signature: ____________________________________ Date: ____________________

PLEASE MAIL COMPLETED FORMS AND CHECK TO:

Crossfit Bloomington Normal Kids 401 Bronco Dr. Unit D, Bloomington, IL 61704