Waiver, Informed Consent & Covenant

This form is an important legal document. It explains the risks you are assuming by beginning an exercise program. It is critical
that you read and understand it completely. After you have done so, please print your name legibly and sign in the spaces
provided at the bottom.

Waiver, Informed Consent and Covenant not to Sue

I, ______________________________, have volunteered to participate in a program of physical exercise under the direction of The Gem Factory, which will include, but may not be limited to, weight and/or resistance training. In consideration of Mindset Fitness Training agreement to instruct, assist and train me, I do here and forever release and discharge and hereby hold harmless The Gem Factory and their employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting therefrom. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK; AND (2) ANY SLIP, FALL DROPPING OF EQUIPMENT (3) ANY INJURY THAT MAY OCCUR AS A RESULT OF EXERCISING OUTDOORS INCLUDING CAR ACCIDENT AND INJURIES RELATED TO GLASS OR OTHER DEBRIS ON EXERCISE SURFACES.

Assumption of Risk

I, _____________________________, recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat, heart attack and, in rare instances, death.

I, _________________________ understand that as a result of my participation in an exercise program, I could suffer an injury or physical disorder that could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I recognized that an examination by a physician should be obtained by all participants prior to involvement in any exercise program. If I, ________________________, have chosen not to obtain a physician’s permission prior to beginning this exercise program with The Gem Factory, I hereby agree that I am doing so at my own risk.

In any event, I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate.

I acknowledge and agree that no warranties or representation have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary.

I ACKNOWLEDGE THAT I HAVE THOUROGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND
THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY
SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST THE GEM FACTORY FOR
YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES.

Participants Signature

Date

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