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Newport Boxfit
PWR!Moves® - Fight Parkinson's
Liability Waiver and Release

Welcome to Newport Boxfit. Quick signup then we can concentrate on the workout!

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How did you hear about us?

Risk Factor Questionnaire

Have you been hospitalized in the last 12 months?
Have you ever had, or has your doctor ever diagnosed you as having heart trouble or coronary disease?
Do you have a family history of high blood pressure, coronary disease or stroke?
Do you smoke cigarettes?
Do you ever feel faint or have dizzy spells?
Do you have any injuries (past or current) or conditions we need to know about?

Health & Fitness History

Informed Consent

By signing this document I acknowledge that I have voluntarily chosen to participate in Undefeated - Fight Parkinson's presented by Newport Boxfit which is a program of aggressive physical exercise, which can enhance the musculoskeletal and cardiovascular systems. In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible physiological results including but not limited to abnormal blood pressure, fainting, heart attack or death. I acknowledge that I have discussed with my medical care providers the advisability of my participating in the program and have fully informed said providers of the nature of the physical exercise involved.

 

​I hereby release and absolve Jesse Macrae, Andrew Menton, Newport Boxfit, Pulse Newport and all employees, agents, officers, directors, and other persons from any and all liability for injury, disability, death, or other loss incurred by me while using the facilities and equipment and engaging in personal fitness training and other activities except that this release shall not apply to willful malfeasance or intentional wrongdoing.

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I covenant not to commence any lawsuit or take any other proceeding or action against Jesse Macrae, Andrew Menton, Newport Boxfit, Pulse Newport, or any employees, agents, officers, directors, and other persons for any such liability, each and I agree to indemnify and hold harmless from any and all liability, loss, costs and expenses. including reasonable attorney's fees, they may incur in the event of any loss incurred.

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I authorize Newport Boxfit LLC to use photos, and or videos of myself and or my child or the child for whom I have legal guardianship for any promotional materials regarding Newport Boxfit programs, facilities, or services. Material will not be sold to other parties. Promotional materials bearing these likenesses may be distributed for free to the public and posted on the Newport Boxfit website and social media. Newport Boxfit reserves the right to use any photo or likeness for a time period beginning when this form is signed and ending upon written request of participant, parent or legal guardian

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I understand that questions about exercise procedures and recommendations are encouraged and welcomed

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