Name *

First Name

Last Name

Birth Date

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Do you have any health conditions, injuries or conditions that would affect your ability to complete physical exercise?

Yes

No

Waiver *

I UNDERSTAND THAT: By participating in The Box - CrossFit Waitakere (The Box) on site activities, I agree to abide by The Box rules for safe use and the user courtesy guidelines established by The Box. I acknowledge that the use of facilities on site involves the possible risk of injury and/or damage and subject to any rights I may have pursuant to the Consumers Guarantees Act 1993. I agree that by using these facilities I personally assume that risk and release The Box and it’s trainer , contractors and employees from any liability, claims, losses, damages or expenses caused by or arising out of or in connection with my use of the facilities including, but not limited to; personal injury or death, property loss or damage, any other loss, damage, suffering, emotional or nervous shock or discord. In signing this form I confirm that I suffer from no physical or medical condition which may be aggravated by my use of the facilities. I consent to receive medical treatment in the case of injury, accident or illness which I may suffer in the course of or connected with my use of the facilities at the centre and agree to indemnify The Box and its trainers, contractors and employees against any claims in respect of such treatment. I agree that subject to any rights I have pursuant to the Consumers Guarantees Act 1993, I will not bring any action proceeding or litigation against The Box or any trainers, employees/contractors for risks or perils seeking compensatory or any other form of, damages in any court in New Zealand or in any other country. I agree that my successors, executors, and administrators and next of kin are bound by the provisions of this release form.

I Agree

I Disagree