8/19/2019 Sample CrossFit Kids Waiver (1)

1/2

CrossFit 915 Kids- Information Card, Waiver & Photo Release

Child’s Name: Age: DOB:

 Address: City, State, Zip:

Parent/Guardian Name(s

Ph!ne: "mail:

"mergen#y C!nta#t Name: Ph!ne:

"mergen#y C!nta#t Name: Ph!ne:

PHYSIC! C"I#I"Y

•   $hat is y!ur  #hild’s #urrent le%el !&  a#ti%ity' 

•   D!es y!ur  #hild parti#ipate in team sp!rts'  & yes, )hi#h !nes' 

•   Appr!*imate num+er  !&  minutes per  day !&  physi#al a#ti%ity 

$%%R! H%!"H

as y!ur #hild su&&ered !r +een diagn!sed )ith any !& the &!ll!)ing'

n-ury (.ar 0 !r N Date !& 

!##urren#e

Status !& re#!%ery

Br!en +!nes

ead trauma

eart C!nditi!n

 Allergies

 Asthma

 ADD

Other in-uries !r #!nditi!ns

• D!es y!ur #hild tae any pres#ripti!n !r !%er the #!unter medi#ati!ns' & yes, please list:

•   D!es y!ur  #hild need a res#ue inhaler' 

• D! y!u /n!) any reas!n )hy y!ur  #hild sh!uld n!t parti#ipate in physi#al a#ti%ity'

•

  Additi!nal in&!rmati!n: 

D!#t!r’s Name: 

Ph!ne: 

8/19/2019 Sample CrossFit Kids Waiver (1)

2/2

Waiver and Release of !ia'ilit() CrossFit 915 Kids

H%!"H *"IFIC"I*C1OSS23 456 7DS S"18C"S A1" NO3 A S9BS3393" 2O1 P1O2"SSONA ."DCA AD8C" O1 A ."DCA ";A.NA3ON< P1O13O 0O91 CD’S PA13CPA3ON N AN0 P1OG1A., AC3830 O1 ";"1CS" 0O9 SO9D S""7 3" AD8C" O2 0O91 P0SCAN O1O3"1 =9A2"D "A3CA1" P1O2"SSONA< 0O9 9ND"1S3AND 3A3 3"S" ";"1CS"S CAN B" S31"N9O9S AND SO9D B"DON" N .OD"1A3ON< 3"1" S AN N"1"N3 1S7 N AN0 ";"1CS" 3A3, $" P1O8DNG "A3 B"N"23S, CAN ASO CA9S"9N7NO$N "A3 SS9"S< APPCA3ON O1 1"ANC" ON 3" 3"CN=9"S, AD8S", D"AS AND S9GG"S3ONS O2 AN0 P"1SON

 ASSOCA3"D $3 C1OSS23 456 A1" A3 3" SO" DSC1"3ON AND 1S7 O2 3" PA13CPAN3 AND S/"1 PA1"N3 ANDG9A1DAN<

WI#%R

AG1"", B0 AO$NG .0 CD 3O PA13CPA3" N AN0 P1OG1A. ASSOCA3"D $3 C1OSS23 456 7DS, 3A3 C1OSS23 456

7DS AND O1S"PO$"1 A3"3CS, C DBA C1OSS23 456 SA NO3 B" AB" 3O AN0 D1"C3, ND1"C3, SP"CA

CONS"=9"N3A O1 ";".PA10 DA.AG"S 2O1 AN0 N>910 O1 A1. 3O 0O9 AND 0O91 CD NC911"D N O1 A1O9ND 3"

P1OP"130 $"1" ";"1CS" OCC91S< $NG0 ASS9." 29 1"SPONSB30 2O1 3" 1S7S 3A3 A. ";POSNG .0 CD

3O AND ACC"P3 29 1"SPONSB30 2O1 AN0 N>910 O1 D"A3 3A3 .A0 1"S93 21O. S/"1 PA13CPA3ON N AN0 AC3830

O1 CASS 2AC3A3"D B0 C1OSS23 456 <

R%!%S%

N CONSD"1A3ON O2 3" ABO8" ."N3ON"D 1S7S AND AZA1DS AND N CONSD"1A3ON O2 3" 2AC3 3A3 A. $NG0 AND

8O9N3A10 AO$NG .0 CD’S PA13CPA3ON N 3" AC383"S A8AAB" A3 C1OSS23 456 , "1"B0 1""AS" C1OSS23

456 7DS, .A1C AND A.0 D9C"N", AND C1OSS23 456 , 3"1 P1NCPAS, AG"N3S, ".PO0""S AND 8O9N3""1S 21O. AN0

 AND A AB30, CA.S, D".ANDS, AC3ONS O1 1G3S O2 AC3ON, $C A1" 1"A3"D 3O, A1S" O93 O2, O1 A1" N AN0 $A0

CONN"C3"D $3 .0 CD’S PA13CPA3ON N 3S AC3830, NC9DNG 3OS" A"G"D0 A331B93"D 3O 3" N"GG"N3

 AC3S O1 O.SSONS O2 3" ABO8" ."N3ON"D PA13"S< , 3" 9ND"1SGN"D AC7NO$"DG" 3A3 .0 CD AS NO P0SCA

.PA1."N3S O1 N"SS"S 3A3 $ "NDANG"1 ./"1 O1 O3"1S<

I CS% *F %+%R$%CY

G8" 29 P"1.SSON 2O1 AN0 P"1SON CONN"C3"D 3O C1OSS23 456 7DS O1 C1OSS23 456 3O AD.NS3"1 21S3 AD

D""."D N"C"SSA10, AND N CAS" O2 S"1O9S N"SS O1 N>910, G8" P"1.SSON 3O CA 2O1 ."DCA AND/O1 S91GCA

CA1" 2O1 3" CD AND 3O 31ANSPO13 3" CD 3O A ."DCA 2AC30 D""."D N"C"SSA10 2O1 3" $"?B"NG O2 3"

CD<

PH*"*$RPHY#I%* R%!%S%

PA13CPAN3S N8O8"D AN0 AC383"S O22"1"D B0 C1OSS23 456 .A0 B" PO3OG1AP"D O1 8D"O3AP"D D91NG 31ANNG<

3" 9ND"1SGN"D "1"B0 CONS"N3S 3O 3" 9S" O2 3"S" PO3OG1APS AND/O1 8D"OS $3O93 CONS"N3 O1

CO.P"NSA3ON ON 3" C1OSS23 456 $"BS3" O1 N AN0 "D3O1A, P1O.O3ONA O1 AD8"13SNG .A3"1A P1OD9C"D B0C1OSS23 456 <

I%+IFIC"I*

1"COGNZ" 3A3 3"1" S A 1S7 N8O8"D N 3" 30P"S O2 AC383"S O22"1"D B0 C1OSS23 456 < 3"1"2O1" ACC"P3

2NANCA 1"SPONSB30 2O1 AN0 N>910 3A3 .0 CD O1 .A0 CA9S" "3"1 3O .0S"2 O1 3O O3"1S< SO9D 3"

 ABO8" ."N3ON"D PA13"S O1 AN0ON" AC3NG ON 3"1 B"A2 B" 1"=91"D 3O NC91 A33O1N"0’S 2""S AND COS3S 3O

"N2O1C" 3S AG1""."N3, $ 1".B91S" 3". 2O1 S9C 2""S AND COS3S< AG1"" 3O ND".N20 AND OD A1."SS

C1OSS23 456 , 3"1 P1NCPAS, AG"N3S, ".PO0""S, AND 8O9N3""1S 21O. AB30 2O1 3" N>910 O1 D"A3 O2 AN0

P"1SON(S AND DA.AG" 3O P1OP"130 3A3 .A0 1"S93 21O. .0 N"GG"N3 O1 N3"N3ONA AC3 O1 O.SSON $"

PA13CPA3NG N AC383"S O22"1"D B0 C1OSS23 456 <

CC%P"C%

, 3" 9ND"1SGN"D, DO "1"B0 8"120 3A3 3" ABO8" N2O1.A3ON S 319" AND CO11"C3< A8" 1"AD AND 9ND"1S3AND

3" 2O1"GONG AND 3A3 B0 SGNNG@ 3 OBGA3"S ." 3O ND".N20 3" PA13"S NA."D 2O1 AN0 AB30 2O1 N>910 O1

D"A3 O2 AN0 P"1SONA AND DA.AG" 3O P1OP"130 CA9S"D B0 ."<   9ND"1S3AND 3A3 B0 SGNNG B"O$, A. $A8NG

8A9AB" "GA 1G3S, NC9DNG 3" 1G3 3O S9"<

Parti#ipant’s Name Parent/Guardian Name Parent/Guardian Signature Date

x

x

x

x

x