Release & Registration Form 

Registration                                      

Name of participant (print):                                                                    DOB:                         

Address:                                                           City:                                        Zip:                  

Home Phone:                             Alternate Phone:                              Email:                          

In case of an emergency contact:

Name (print):                                                                Relationship:                                        

Home Phone:                                        Work / Alt. Phone:                                                        Email:______________________

Referral Source:                                                                                                                       

Rules of Participation

1)      Eligibility – Only clients (if minor must have parental consent) whom have read and signed the Registration and Rules of participation t of Risks and Release of Liability forms and have paid program fees are eligible to participate in activities and programs.  Guests are not permitted to participate.

2)      Observation – Parents and / or guests of clients are welcome in the gym as observers only.  Parents and / or guests are not allowed to participant in activities or use the equipment.

3)      Supervision – Our staff will instruct proper exercise technique and use of equipment while progressing exercises appropriately.

4)      Equipment use – Equipment is only to be used as intended, following guidelines from the manufacturer, and by clients following staff instruction.

5)      Responsibilities of the client – Use of illegal drugs, alcohol, and / or tobacco is not allowed in this facility. The client is to be respectful to staff and other clients. Horseplay and foul language will not be tolerated. The client is responsible for his or her actions and violation of any of these responsibilities could lead to removal from participation in programs without refund for unused session(s) or payment toward the program.

6)      Rights of the client – The client has the right to stop participation and / or refuse an exercise for any reason.

7)      Termination – Either party can terminate this agreement at any time, for any reason without refund of unused session(s) or payment towards the program. This applies to all multiple visit packages, month to month participation, or per use participation.

8)      All clients must read, understand, and sign this agreement and a Consent of Risks and Release of Liability prior to participation. Upon being accepted as a client, the client agrees to abide by all the current and future policies of Breakaway Sports Training LLC.

Signature of participant:                                                                     Date:                          

Signature of parent:                                                                            Date:                          

(if participant is a minor)

Consent of Risks and Release of Liability        

A)        Parental Permission (if participant is a minor)

 The undersigned(s) being the lawful parent(s) and / or guardian(s) of the child (the “Child”) hereby consents to the participation by the child in programs conducted by Breakaway Sports Training and Aspen Healthcare (the “Organizer”) and to the participation of the child to the activities.

B)        Medical Consent

The undersigned hereby further authorize(s) any of the staff, employees, agents, and representatives of the organization to provide for, approve, and authorize any health care at any hospital, emergency room, doctor’s office or other institution; employ any physicians, dentists, nurses or other person whose services may be needed for such health care; review and if necessary, disclose the contents of any medical records; except any consent form required by medical, dental, or other health authority incident to the provision of medical, surgical, or dental care to the person / child. Health care shall include but not limited to the administration of anesthesia, x-ray examination, and performance of operations, diagnostic and other procedures.

If there is no medical emergency, the organization will first use reasonable efforts to contact the parent(s) and / or legal guardian(s) before administering or authorizing treatment.

Not withstanding the other provisions to this consent form, the organizer shall not have the authority to withhold or withdraw life-sustaining procedures for the person / child.

C)        Informed Consent of Risks and Release of Liability

The undersigned assume(s) all risks of injury or harm to the person / child associated with the participation in the activities and agree(s) to releases, indemnify, defend and forever discharge the organization and its staff, employees and agents (collectively the “Organization”) of and from all liability, claims, demands, damages, costs, expenses, actions and causes of action (collectively the “Claims”) in respect of death, injury, loss or damage to the person / child or by the person / child, however caused, arising or to arise by reason of or during the person / child’s participation in the activity.

I,                                                                      , am giving this release to Breakaway Sports Training, LLC and its affiliates, and to all of its employees, owners, and directors, (herein referred to “Breakaway

Sports Training, LLC”). This release is given in connection with my participation in activities and programs at 881 Tallmadge Rd., Brimfield, OH 44240. As a condition of my participation, Breakaway Sports Training, LLC has required, and I have confirmed from my physician, that I do not have medical issues that would disqualify me from participating in these activities and programs. Based on the foregoing, I, on behalf of myself and my heirs, beneficiaries, and assigns, hereby release Breakaway Sports Training, LLC from any and all claims, cause of action, costs, expenses, known or unknown, which I may have or could claim to have against Breakaway Sports Training, LLC  relating to my participation in these activities and programs. I understand that this release includes but is not limited to all claims for personal injury, damages and other consequences, whether currently anticipated or not, arising or resulting from my participation in these activities and programs.

By signing below, I acknowledge that I have carefully read and fully understand the provisions of this release, and that I am signing this release knowingly and voluntarily. I agree that this release constitutes the total and complete understanding between myself and Breakaway Sports Training, LLC relating to this subject matter covered by this release.

Signature of participant:                                                         Date:                                     

Signature of parent:                                                                Date:                                      

(If participant is a minor)