General Information
Name: [text* Name]
DOB: [date* dob min:1920-01-01 max:2016-01-01]
Age: [number* age min:5 max:100 “18”]
Name of Parents/ Guardian if under 18: [text GuardianName]
Address: [text* Address]
Contact Information
Cell Phone: [tel* Cell_Phone]
Email: [email* emailaddress]
Receive News Letter emails: [select Emails_NewsLetter “Yes” “No”]
Receive notification of class schedule changes/cancellations: [select Emails_ClassShedule “Yes” “No”]
Emergency Contact
Name: [text* Emergency_Name]
Phone: [tel* Emergency_Phone]
Necessary Medical Information
Allergies: [textarea Allergies]
Relevant Medical History: [textarea MedicalHistory]
Any Activity Restrictions: [radio ActivityRestrictionsYN default:1 “No” “Yes”]
If Activity Restrictions please explain: [textarea ActivityRestrictions]
Health Insurance
Note: If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while participating in a class related activity.
Do you have health insurance?: [radio Health_Insurance default:1 “No” “Yes”]
Name of Insurance Provider: [text InsuranceProvider]
Policy Number: [text InsurancePolicyNumber]
Medical Release: In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by Revival’s leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter, as deemed necessary.
Liability Release: Every activity sponsored by Revival Athletics and Wellness is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, the parents or guardian agree to assume and accept all risks and hazards inherent in class related activities. They also agree not to hold Revival Athletics and Wellness, CrossFit Simplicity or its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release.
Media Release: Please document below in writing if you do not want photos of yourself to be shared on our ministry website or social media platforms. Media Release Decline: [text MediaDecline]
[acceptance ReleaseFormAccept] I have read and understand the medical release, liability release and media release. [/acceptance]
Enter your full name to digitally sign: [text* ReleaseFormSign]
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Support Assistant
[submit “Submit Release Form”]