Chalk Performance Training

121 18th St
Costa Mesa, CA 92627
www.chalkperformancetraining.com
Chalk Waiver - READ ONLY

Full Name Email Address Gender

Rahil Patel patelsumaiya2210@gmail.com Male
Street Address City Province/Region Zipcode
A-7 karbhari park Vadodara Gujarat 390007
Country Date of Birth Phone
India 09/04/1982 +919998186292
Emergency Contact Name Emergency Contact Phone
9979423494 +919979423494

MOVMT LLC. is an California Limited Liability Company doing business as Chalk Performance Training.

Informed Consent/Assumption of Risk

I am aware there are significant risks involved in all aspect of physical training. I understand the reaction of my heart, lungs and vascular system due
to exercise cannot always be predicted with accuracy. I understand that there is a risk of certain abnormal changes occurring during or following
exercise which may include abnormalities of blood pressure, heart rate, chest, arm or leg discomfort: transient light-headedness or fainting; and in rare
instances heart attack, stroke, or death. Excessive work can result (in rare cases) in exertional rhabdomyolysis. I should look for signs of excessive
soreness, darkened urine or pain in the kidney areas following intense workout. While this type of injury is rare, it can occur due to a number of
factors, including (but not limited to) genetic predisposition or dehydration, that may beyond the control of my instructor. I understand the
programs and classes offered by Chalk Performance Training are of a nature and kind that are extremely strenuous and can/may push me to my
limits and abilities. These risks include, but are not limited to: improper use or failure of equipment, falls, which could result in serious injury or death
due to my negligence, my training partner, or other people around me. I am aware that any of these above mentioned risks may result in serious
injury death to my partners or myself.

PAR Q & Informed Consent/Waiver

I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in any activities, class, or physical
fitness program. I hereby certify that I know of no medical problems that would increase my risk of illness or injury as a result of my participation in a
fitness program designed by Chalk Performance Training. With my full understanding of the above information, I agree to assume any and all risk
associated my participation in Chalk Performance Training programs and classes. By signing this document, I acknowledge that I have voluntarily
chosen to participate in a program of progressive, physical exercise. By signing this document, I acknowledge being informed of all the strenuous
nature of the program and the potential for usual but possible, physiological results including but not limited to, abnormal blood pressure,
rhabdomyolosis, fainting, heart attack, stroke, or death. By signing this document, I assume all risk for my health and well-being and hold Chalk
Performance Training as well as its owners, employees, independent contractors, and other authorized agents harmless there from. I understand that
questions about exercise procedure and recommendations are encouraged and welcome.

Waiver & Release

I fully understand that my personal exercise program may be strenuous and I choose to participate voluntarily. I accept all responsibility for my heath
and any results, injury or mishap that may affect my well-being or health in any way. I waive any claims, demands cause of action of any claims for
relief whatsoever against Integrated Chalk Performance Training (as well as any of its owners, employees, or other authorized agents, including
independent contractors) from any and all liability, claims and/or causes of action that I may have for injuries or other damages, arising out of
participation Chalk Performance Training activates, including, but not limited to the personal training, programs, class, and nutritional programs.

Indemnification

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I recognize that there is a risk involved in the type of activities offered by Chalk Performance Training and therefore I accept full financial responsibility
for any injury that I may cause either to myself 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 cost to enforce this agreement, I agree to reimburse them for such fees and
costs. I further agree to indemnify and hold harmless Chalk Performance Training, their principals, agents, employees, and volunteers, from any
liability for the injury or death of any people or damages to property that may result from my negligent or intentional act or omission while
participating in activities offered by CrossFit Chalk.

Arbitration/Governing Law

This agreement shall be governed by and constructed on accordance with the laws of the state of California without regard to the principles of the
conflicts of law thereunder. Any dispute, claim, or controversy arising out of or relating to this agreement or to the breech, termination, enforcement,
interpretation determined by arbitration in Costa Mesa, California before one neutral arbitrator. The arbitration shall be administered by the American
Arbitration Association under its commercial Arbitration rules and both Chalk Performance Training and I consent to any such dispute being resolved.
Judgment on the award rendered in any such arbitration may be entered in any court having jurisdiction. The prevailing party in any proceeding,
including but not limited to arbitrations hereunder, arising out of or relating to this Agreement shall be entitled to his/her or its reasonable attorney’s
fees and costs.

Validity

I have fully READ and 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 damages property caused by my negligent or intentional act or
omission. I understand by signing this document, I am WAIVING valuable legal rights.

I have carefully read this Agreement and fully understand its content. I am aware that is a release and waiver of liability and sign it knowingly,
voluntarily, and do so of my free will.

Rah *

Photo, Image & Likeness

Member hereby grants Chalk the right at no cost to use Member’s photo, image and likeness in any social media posting, including but not limited to
Facebook, Instagram, Vine, as well as any blog, or website posting of Chalk. Member shall further grant the right to Chalk at no cost to use Member’s
photo, image and likeness in any print advertising, brochures, flyers, promotional product or medium as long as such use is not for commercial gain or
sale of such good or medium. (For example, t-shirt sales, fitness Chalk warrants and agrees that it will not use Member’s photo, image or likeness for
commercial gain but solely for advertising and promotional purposes. If Member wishes to revoke this right to any photo, image or likeness that is
being used, it must provide such notice in writing and allow Chalk thirty (30) business days to remove, delete, cancel or otherwise stop the use of
such Member photo, image or likeness.

Rah *

EFT REQUEST & AUTHORIZTION

Client authorizes Chalk Performance Training or its assigns to make periodic charges or withdrawals from the account used to pay the initial described
above or the account listed below or replacement account designated by Client and accepted by Chalk Performance Training for payment of any and
all fees, late charges, costs, expenses or any other money due to Chalk Performance Training under the terms and conditions of this agreement.
Client understand that the client is entitled to notice of all varying charges cost, withdrawals under the EFT, expenses or any other money due to
CrossFit Chalk under the terms and conditions of this Agreement. Client waives the right to receive prior notice for charges or withdrawals made with
respect to any uncollected payments or portions of the balance due described above and the corresponding service charges, both of which client
agrees are not varying charges or withdrawals. Client may change the account designated herein upon thirty (30) days written notice to, and
approved by Chalk Performance Training. Client may timely notify the financial institution in control of client’s account to terminate this request, but
such notification will constitute a default and may cause all sums under this agreement to be due and payable immediately together with all costs of
collection o to extent permitted by law. Chalk Performance Training or it is assign reserves the right to add the following fees to the clients account
balance should the following occur: resubmit unpaid EFT draft - ($10); unpaid EFT draft - ($15); unpaid credit/debit card - ($15). Payments received
more than ten (10) days after the due date are assessed a late fee - ($15).
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IMPORTANT NOTE: Client, by agreeing to partake in Chalk Performance Training personal training/Nutritional program service and related activities,
agrees to release Chalk Performance Training from liability due to participation. Client is urged to have this release agreement reviewed by their
attorney before signing.

By signing this agreement, Client acknowledges that client has read, understood and agrees with all the terms and conditions of this agreement after
having the opportunity to have it reviewed by an attorney at the discretion of the Client. Client further acknowledges and received a filled-in and
completed copy of this agreement, which includes EFT request, the release and waiver of liability, and additional terms and provisions of the
agreement. This agreement constitutes the entire agreement of the parties and no other agreement or understanding exist between clients and
Chalk Performance Training. Chalk Performance Training has made no express or implied warranties or misrepresentations other than those expressly
set forth in this agreement to include client to enter into this agreement. Any conflict between the original agreement and any copy of the original
agreement, shall be controlled by the original agreement.

THIS AGREEMENT IS FINAL, THERE IS NO COOLING OFF PERIOD. FOR MONTHLY MEMBERSHIPS WE REQUIRE 30 DAYS NOTICE TO CANCEL YOUR
MEMBERSHIP.

Rah *

Has your doctor ever said that you have a heart condition and you should only do physical activity recommended
by a doctor ?
Yes No

Do you feel pain in your chest when you do a physical activity ?

Yes No

In the past month, have you had chest pain when you were not doing physical activity ?
Yes No

Do you lose your balance because of dizziness or ever lose consciousness ?

Yes No

Do you have bone or joint problems (neck, shoulder, back, knee or hip) that could be made worse by changing
your physical activity ?
Yes No

Are you taking any prescription drugs for blood pressure, cholesterol or heart condition ?
Yes No

Do you know of any reason why you should not be allow to do any physical activities ?
Yes No

Date Signed:
12/25/2020

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Please read the Electronic Records and Signature Disclosure
I agree to use electronic records and signatures

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