Pre-Exercise Health Assessment and Waiver / Release of Liability

Activate Lifestyle Management Pty Ltd, Trading as: Outlier TV

PO Box 1229, Manly NSW Australia 1655

Personal Information

Please Note:

i) If you are a parent and participating in the Outlier Program with one or more of your children please fill in the questions for yourself and your applicable children below

ii) If you are filling in this form for yourself only, please do not fill in the questions for participant two below.

iii) If you have more than 2 participants you will need to fill in the details of your additional participants in a separate Pre-Exercise Health Assessment and Waiver / Release of Liability by purchasing another membership.

iv) If you are not participating as a parent in the Outlier Program then just fill in your child / children’s questions below and sign the parent / guardian declaration underneath each participant.

How many participants are you filling in this form for?

One

Two

First Name

Last Name

Email

Phone

Date of Birth

Emergency Contact Name (1)

Emergency Phone (1)

Relationship to You (1):

Emergency Contact Name (2)

Emergency Phone (2)

Relationship to You (2)

Have you ever had any form of Heart Disease?

Yes

No

Do you have any current Injuries? If Yes, please list the Injury(ies) – Knee, Ankles, Hip, Back, Neck, Shoulders etc.

Have you ever experienced Shortness of Breath or Chest Pains?

Yes

No

Do you have any Allergies? If Yes, please list the Allergy(ies)

Do you have a family history of Heart Disease?

Yes

No

Are you currently taking any Medication(s)? If yes, list the Medications.

Are you a Smoker?

Yes

No

Are you currently Exercising / Playing Sport?

Yes

No

If Yes, How Many Times a Week?

If Yes, Which Sport(s)?

Do you have High Blood Pressure?

Yes

No

Do you ever get Dizzy?

Yes

No

Are there any exercises that you know you cannot do? If Yes, Which Exercises?

Participant Two

First Name

Last Name

Email

Phone

Date of Birth

Have you ever had any form of heart disease?

Yes

No

Do you have any current Injuries? If Yes, please list the Injury(ies) – Knee, Ankles, Hip, Back, Neck, Shoulders etc.

Have you ever experienced Shortness of Breath or Chest Pains?

Yes

No

Do you have any Allergies? If Yes, please list the Allergy(ies)

Do you have a family history of Heart Disease?

Yes

No

Are you currently taking any Medication(s)? If Yes, please list the Medication(s

Are you a Smoker?

Yes

No

Are you currently Exercising / Playing Sport? If Yes, How Many Times a Week?

If Yes, Which Sport(s)?

Do you have High Blood Pressure?

Yes

No

Do you ever get Dizzy?

Yes

No

Are there any exercises that you know you cannot do? If Yes, Which Exercises?

Participant's Signature: (type your full name)

Date

Participant Two’s Signature: (type your full name)

If one or both of the participant(s) is under the age of 18,

Yes

No

Signature of Parent or Guardian (type your full name)

By typing my full name above (as my signature) and clicking the Submit Now button underneath the Waiver and Release Of Liability Agreement below, I confirm I have completed all of the appropriate questions above (for myself if I am participating in the Outlier Program and / or for any of my child(ren who are participating) and agree to all terms related to the Waiver and Release Of Liability Agreement.

Waiver and Release of Liability

Activate Lifestyle Management Pty Ltd, Trading as: Outlier TV

PO Box 1229, Manly NSW Australia 1655

Please note:

i) The terms “I” and “me” below refers to one (and/or two participants) that you are filling in this waiver for.

In consideration of Outlier TV and its trainers allowing me to participate, I acknowledge, understand and are aware that:

I have voluntarily chosen to participate in training activities provided by Outlier TV and its trainers.

I understand there are inherent risks in all aspects of physical training and I acknowledge that I have been informed of the possible strenuous nature of the training and the potential for undesirable physiological results including, but not limited to, abnormal blood pressure, muscle soreness, fainting, heart attack and/or death.

I understand that the training may involve weightlifting, gymnastic movements, strenuous bodyweight exercises, stretching and other high exertion activities, and that I am not obligated to perform nor participate in any activity that I do not wish to perform, and that it is my right to refuse such participation at any time during my training sessions.

I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my trainer. I give any Outlier TV staff of the location I train at permission to seek emergency medical services for me should I become injured or ill with the understanding that I am responsible for any expenses incurred.

I agree to WAIVE ANY AND ALL CLAIMS that I have or may have in the future against Outlier TV directors, officers, employees, agents, volunteers and independent contractors (all of whom are hereinafter collectively referred to as “the Releasees”). I agree to RELEASE THE RELEASEES from any and all liability for any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer as a result of my participation in the programs, activities and services provided by Outlier TV and its trainers due to any cause whatsoever including negligence, breach of contract, or breach of any statutory or other duty of care.

I agree to HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any damage to the property of, or personal injury to, any third party, resulting from my participation in any program, activity or service provided by the releasees.

This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.

If I am signing on behalf of a minor child, I also give full permission for any person connected with Outlier TV and its trainers to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical care for the child and to transport the child to a medical facility deemed necessary for the wellbeing of the child.

Use of picture(s)/film/likeness: I agree to allow Outlier TV, its agents, officers, principals, employees and volunteers to use picture(s), film and/or likeness of me for advertising purposes. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform Outlier TV of this in writing.

I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS “INFORMED CONSENT FORM” I AM WAIVING CERTAIN LEGAL RIGHTS (INCLUDING THE RIGHT TO SUE) WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTOR, ADMINISTERS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES.

ANY QUESTIONS I HAD WERE ANSWERED TO MY FULL SATISFACTION.

Thank you!

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