848 Rt. 314
Swiftwater, PA 18370
I acknowledge the risks inherent in the activities that I am about to enter and for this facility and location where
the activities take place. All of these risks have been carefully explained to and understood by me. These risks
include, but are not limited to, joint pain and strain, muscle soreness, tears, and strains, bone fractures,
amenorrhea (interruption or cessation of menstrual cycle resulting from excessive exercise), miscarriage, stroke,
cardiac arrest, death.
I hereby assume those risks. I hereby acknowledge that I will be voluntarily engaging in an activity or activities
involving a risk of harm to me and others. I know and fully understand the risk of harm, and I hereby accept
that risk. Those activities include, but are not limited to, aerobic exercise, strength training, use of bathroom/
shower facilities, exercise testing, and stretching. I voluntarily assume the known and appreciated risks
I knowingly and voluntarily accept these risks of harm. I understand and appreciate the risks involved and
accept those risks as an inherent condition of the various activities in which I will be engaged.
I hereby consent to these activities and to the risks inherent therein.
I have also been advised of my right to, and, in fact, urged to have a complete physical examination, including
but not limited to a stress test and blood work up. Further, I acknowledge that I have been advised to have a
physical examination at least annually and not to embark on any strenuous exercise program without a complete
physical examination. Any medical information that I wish to have brought to the attention of the instructors
and operators of this program are attached to this form, initialed and dated by me, and hereby incorporated by
reference. I hereby waive any claims against anyone involved in performing this contract for any disease,
illness or injury that would have been preventable by the disclosure of a physical examination. I hereby waive
any and all claims against the other party or parties to this contract.
I understand and expressly assume all dangers of these activities, the facility, and location. I waive all claims
arising out of the activities and from the location and facility, whether cause by negligence, breach of contract,
or otherwise and whether for bodily injury, property damage, or loss or otherwise.
To the maximum extent permitted by law, I hereby release all other parties, their employees and agents, from
any liability for any of their actions or inactions through negligence or other wise.
I hereby expressly and without reservation intend to and, in fact, do accept total responsibility for my actions or
inactions which result in damages of any kind to me or to anyone else involved.
In consideration of being allowed to participate, I hereby agree to indemnify and hold harmless those other
persons involved with me in this activity and program and/or the other party or parties to this contract.
Signature: ________________________________________________________________
I acknowledge, agree, and represent that I, the undersigned, the nature of the activities and that I am qualified, in
reasonable health, and i n proper physical condition to participate in such activity and have not been advised
otherwise by a qualified health professional. I further agree and warrant that if at any time I believe conditions
to be unsafe, I will immediately discontinue further participation in the activity.
Also, specifically included herein are parking areas, sidewalks, areas of common usage, and outside areas under
the ownership, control and/or maintenance of any party hereto.
I fully accept that activities involve risks and dangers of serious bodily injury, including but not limited to
permanent disability and/or paralysis, and death; these risks and dangers may be caused by my own actions or
inactions, the actions or inactions of others participating in the activity, the condition in which the activity takes
place, or the negligence of others including but not limited to those named below; that there may be other risks
such as social and economic losses including but not limited to property damage, medical and hospital bills, or
theft either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks
and all responsibility for losses, costs, and damage I incur as a result of my participation in the activity.
I hereby release, discharge, and covenant not to sue CrossFit Pocono (APansy LLC.) their respective board
members and officers, members, organizers, volunteers, other participants, and, if applicable, owners and
leasers of the premises which the activity takes place (each considered one of the “RELEASEES” herein) from
liability, claims, demands, losses, or damages on my account caused or alleged be caused in whole or in part by
the negligence of the RELEASEES or otherwise, including negligent rescue operations, and I further agree that
if, despite this release and waiver of liability, assumption of risk, and indemnity agreement I, or anyone on my
behalf, makes a claim against any of the RELEASEES, I shall indemnify, save and hold harmless each of the
RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which may incur as a
result of such claim.
In addition to covering events occurring in the facility, on its grounds, and/or in the parking area, this Waiver
and Release of Liability also covers any and all off premises activities in which I am in any way involved with
the releasees.
I fully intend that this agreement shall bind me, my heirs, distributees, assigns, and anyone claiming any interest
through me. My rights have been fully explained to me, and I hereby enter into this agreement to induce the
other party or parties to enter into it and to provide the goods or services to me as contemplated by our various
I have read this agreement, fully understand its terms, understand that I have given up substantial rights by
signing it and have signed freely and without any inducement or assurance of any nature and intend it to be a
complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any
portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and
Dated: __________________________________
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