Liabilty Waiver
Trial Session Release
Athlete’s Name: _______________________________ Age: _________ DOB: ______________
Address: _____________________________________ City: _____________________________ State: _____ Zip: ___________
Home Phone: ______________________________Cell Phone: ____________________________
Email Address: _____________________________________________________________________________________________
A. PAST INJURIES
Injury Details
Neck _______________________
Shoulder _______________________
Elbow _______________________
Arm/wrist/hand _______________________
Rib cage _______________________
Back _______________________
Hip _______________________
Thigh _______________________
Injury Details
Knee _______________________
Lower leg _______________________
Ankle _______________________
Foot _______________________
Muscle strains _______________________
Joint sprains (specific) _______________________
Concussion(s) (#) _______________________
Skull fracture(s) (#) _______________________
Additional information we might need to know:
Any injury to any part not mentioned? __________________________________________________________________
False teeth or bridge? ________________________________________________________________________________
Ever had an arthroscopy? What joint(s)? _______________________________________________________________
Ever been advised to restrict activity during the past 5 years? _____________________________________________
B. PAST ILLNESS OR MEDICAL CONDITIONS
Do you have, or have you ever had, any of the following conditions? If so, please check and provide date:
Surgeries _______________________
Confinement to hospital _______________________
Frequent headaches _______________________
Fainting spells or dizziness _______________________
Epilepsy or convulsions _______________________
Numbness or tingling _______________________
Nosebleeds _______________________
Difficulty hearing _______________________
Heart murmur _______________________
Arthritis _______________________
Diabetes (type) _______________________
Any abnormal bleeding tendencies Yes / No
Any allergies
food
medication
skin
asthma - exercised induced
Osgood-Schlatter’s disease of the knee
Hepatitis or jaundice
Acquired Immune Deficiency Syndrom (AIDS)
Infectious mononucleosis
Loss of or serious impairment of, a paired organ
Anything not mentioned or explanation of something we should be aware of:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
As used in this agreement, “Visitor” means the person considering becoming a client or visiting our facility to participate
in a special event conducted there; “you” also means the Visitor, but includes the Responsible Party if the Visitor
is less than 18 years old; the “Responsible Party” is the Visitor’s parent or other adult who is legally responsible
for the Visitor; and “we” means the Velocity Sports Performance franchisee that owns the facility. By signing below,
you agree to all the terms and conditions in this agreement and certify that you have read the entire agreement, so
please read it carefully.
As used in this agreement, “Visitor” means the person considering becoming a client or visiting our facility to participate
in a special event conducted there; “you” also means the Visitor, but includes the Responsible Party if the Visitor
is less than 18 years old; the “Responsible Party” is the Visitor’s parent or other adult who is legally responsible
for the Visitor; and “we” means the Velocity Sports Performance franchisee that owns the facility. By signing below,
you agree to all the terms and conditions in this agreement and certify that you have read the entire agreement, so
please read it carefully.
1. Rules. The Visitor must follow all Velocity rules and regulations for using the facility as well as participating in off-
site activities.
site activities.
2. Damage to Facilities. You are liable for any damages that you or your guests cause to the facility or property on
the premises.
the premises.
3. Waiver and Release. Visitors and their guests assume all risk of personal injury, death, property loss, or other
damages that may relate to attending or using the facility or participating in any of Velocity programs, activities, or
special events. By assuming those risks you and your guests waive, and release, all claims you or your guests may
have or may want to assert against Velocity, its affiliates (including Velocity Sports Performance Franchise Systems),
affiliates’ owners, officers, directors, managers, employees, agents, and representatives (the “VSP Group”)
for any such personal injuries, death, property loss, or other damages connected to or arising out of any of the
aforesaid risks. You and your guests release the VSP Group from all claims, damages, demands, rights of action,
causes of action, and liabilities, present or future known or unknown, anticipated or unanticipated, resulting from
or arising out of the Visitor’s and its guests’ attendance at our use of our facility or their participation in any of our
activities, programs, or special events, including, without limitation, those arising from our negligence or that of any
other member of the VSP Group. You and your guests also release all members of the VSP Group from all liability
relating to loss, theft, or damage to personal property- including, without limitation, automobiles and locker contents.
damages that may relate to attending or using the facility or participating in any of Velocity programs, activities, or
special events. By assuming those risks you and your guests waive, and release, all claims you or your guests may
have or may want to assert against Velocity, its affiliates (including Velocity Sports Performance Franchise Systems),
affiliates’ owners, officers, directors, managers, employees, agents, and representatives (the “VSP Group”)
for any such personal injuries, death, property loss, or other damages connected to or arising out of any of the
aforesaid risks. You and your guests release the VSP Group from all claims, damages, demands, rights of action,
causes of action, and liabilities, present or future known or unknown, anticipated or unanticipated, resulting from
or arising out of the Visitor’s and its guests’ attendance at our use of our facility or their participation in any of our
activities, programs, or special events, including, without limitation, those arising from our negligence or that of any
other member of the VSP Group. You and your guests also release all members of the VSP Group from all liability
relating to loss, theft, or damage to personal property- including, without limitation, automobiles and locker contents.
4. Visitor’s Physical Fitness. You represent that the Visitor is physically fit to engage in the activities in which he or
she participates in the facility. You are solely responsible for all health risks associated with those activities.
she participates in the facility. You are solely responsible for all health risks associated with those activities.
5. Arbitration. All disputes and legal claims that you and your guests may have with or against any member of the
VSP Group must be resolved through binding arbitration conducted by the American Arbitration Association.
VSP Group must be resolved through binding arbitration conducted by the American Arbitration Association.
6. Franchise. We have franchised the right to operate a Velocity Sports Performance business from Velocity Sports
Performance Franchise Systems, LLC, our franchisor. We are, thus, an independently owned and operated business
and not an agent, legal representative, subsidiary, joint venture, partner, employee, affiliate, or servant of
Velocity Sports Performance Franchise Systems, LLC, for any purpose whatsoever. Accordingly, Velocity Sports
Performance Franchise Systems, LLC, has no obligations or liabilities to you under this agreement or otherwise.
Performance Franchise Systems, LLC, our franchisor. We are, thus, an independently owned and operated business
and not an agent, legal representative, subsidiary, joint venture, partner, employee, affiliate, or servant of
Velocity Sports Performance Franchise Systems, LLC, for any purpose whatsoever. Accordingly, Velocity Sports
Performance Franchise Systems, LLC, has no obligations or liabilities to you under this agreement or otherwise.
7. Miscellaneous. We do not honor any oral agreements made at the facility or over the phone that are contrary to
the terms and conditions in this agreement. This contract constitutes the entire legal agreement pertaining to trial
visits and any other matters herein discussed and supersedes any other promises, representations, or understandings
of any kind, whether oral or written. No modifications or alterations to the terms or provisions hereof may be
made by anyone unless such changes are expressly authorized in writing by one of our authorized personnel. If any
provision of this agreement is contrary to, prohibited by, or considered invalid under applicable law, that provision is
inapplicable and considered omitted to the extent it is contrary, prohibited, or invalid—but, in such event, the remainder
of this agreement is not invalidated must be given full force and effect so far as possible. If any provision of this
agreement may be construed in two or more ways, one of which renders the provision invalid or otherwise avoidable
or unenforceable and another of which renders the provision valid and enforceable, the provision has the meaning
that renders it valid and enforceable. We do not lose our right under this agreement if we delay in enforcing them or
fail to enforce such rights.
the terms and conditions in this agreement. This contract constitutes the entire legal agreement pertaining to trial
visits and any other matters herein discussed and supersedes any other promises, representations, or understandings
of any kind, whether oral or written. No modifications or alterations to the terms or provisions hereof may be
made by anyone unless such changes are expressly authorized in writing by one of our authorized personnel. If any
provision of this agreement is contrary to, prohibited by, or considered invalid under applicable law, that provision is
inapplicable and considered omitted to the extent it is contrary, prohibited, or invalid—but, in such event, the remainder
of this agreement is not invalidated must be given full force and effect so far as possible. If any provision of this
agreement may be construed in two or more ways, one of which renders the provision invalid or otherwise avoidable
or unenforceable and another of which renders the provision valid and enforceable, the provision has the meaning
that renders it valid and enforceable. We do not lose our right under this agreement if we delay in enforcing them or
fail to enforce such rights.
Parent/Guardian(print)______________________________ Signature_________________________________________
(If athlete is under the age of 18)
Relationship to Athlete (if not parent)_____________________________________________________
Date__________