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Directions to Speed and Explosion
1560 Georgetown Rd
Hudson, OH 44236
Athletic Release Form
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Athlete Liability Release Form
 Speed & Explosion LTD.
1560 Georgetown Rd. â—? Hudson, OH 44236 â—? 234-380-5225
Name: ____________________________________________________________
Address: ____________________________________________________________
City: ___________________________ State: _________________________
Home: ___________________________ Cell: __________________________
E-Mail: ____________________________________________________________
Emergency Contact (name & number): _______________________________________________________________________________________
INFORMED CONSENT/ASSUMPTION OF RISK:
I, __________________________, agree to participate in one or more physical fitness program(s)/class(es) sponsored by SPEED&EXPLOSION, which may include, but not necessarily be limited to, SPEED&EXPLOSION speed training, plyometric and agility training, boot camp, and/or training of any kind by any affiliate, subsidiary or partnership of SPEED&EXPLOSION and/or Dr. Michael Shimmel (hereinafter collectively referred to as SPEED&EXPLOSION). SPEED&EXPLOSION made me fully aware that the fitness programs/classes which SPEED&EXPLOSION offers and in which I desire to participate are of a nature and kind that extremely strenuous and can/may push me to the limits of my physical abilities. I the undersigned recognize and understand that the programs/classes are not without varying degrees of risk which may include, but are not limited to the following:Â
- injury to the musculoskeletal and/or cardio respiratory systems which can result in serious injury or death.
- injury or death due to negligence on the part of myself, my training partner, or other people around me
- injury of death due to improper use or failure of equipment, or
- injury or death due to a medical condition, whether known or unknown to me.
I am aware that any of these abovementioned risks may result in serious injury or death to myself and/or my partner(s).
Initials: ________
I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in SPEED&EXPLOSION programs/classes and accept full responsibility for any injury or death that may result from participation in any activity, class or physical fitness program. I herby certify that I know of no medical problems that would increase my risk of illness and injury as of participation in a fitness program designed by SPEED&EXPLOSION. SPEED&EXPLOSION informed me that there exists the possibility of adverse physical changes during an exercise program, and I fully understand the same. SPEED&EXPLOSION informed me that these changes could include abnormal blood pressure, fainting, disorder of the heart rhythm, stroke, and in very rare instances, heart attack or even death, and I fully understand the same. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in SPEED&EXPLOSION fitness programs/classes.
Initials: _________
Release:
In full consideration of the above mentioned risks and hazards and in full consideration of the fact that I am willingly and voluntarily participation in the activities mad available by SPEED&EXPLOSION, and with my full understanding of all of the above, I hereby waive, release, remise and discharge SPEED&EXPLOSION and its agents, officers, principals and employees and volunteers, of any and all liability, claims, demands, actions or rights of action, or damages of any kind related to, arising from, or in any way connected with, my participation in SPEED&EXPLOSION programs/classes, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. 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 SPEED&EXPLOSION to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.
Initials: ________
Indemnification:
I recognize that there is risk involved in the types of activities offered by SPEED&EXPLOSION. Therefore I accept financial responsibility for any injury that I or the participant may cause either to him/herself or to any other participant due to his/ her negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless SPEED&EXPLOSION, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by SPEED&EXPLOSION.
Initials: ________
Use of picture(s)/film/likeness:
I agree to allow SPEED&EXPLOSION, 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 SPEED&EXPLOSION of this in writing.
Initials: _________
I have fully read and fully understand the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.
________________________________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â ______________________
Participant's Signature (please sign)Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Today's Date
________________________________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â _______________________
Parent/Legal Guardian Signature (if participant is under 18)Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Today's Date
