Proactivity Indemnity & Release Form

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Please use the form below for your child's Indemnity & Release agreement.

Proactivity Program / Event(Required)

Program / Event Date(Required)

Participant Details

Participant's Name(Required)

First Name Last Name

Participant's Date of Birth(Required)

Participant's Address

Street Address City State Postcode

Participant's Phone Number

Participant's Email Address

Emergency Contact Details

Emergency Contact's Name(Required)

First Name Last Name

Relationship to Participant

Emergency Contact's Phone Number

Participant Health Information

Has your doctor ever advised against strenuous activity?(Required)

Yes

Do you have a history of heart disease or high blood pressure?(Required)

Yes

Do you have any other medical conditions?(Required)

Yes

Medical condition details(Required)

Current injuries?

Past injuries?

Anything else your trainer should know about your physical condition?

Indemnity and Release Agreement

I acknowledge that I have read and understand this Indemnity and Release and agree to be bound by it. I further confirm that all information provided above is truthful, accurate and complete. I desire to engage in this voluntary Proactivity Program to improve my physical fitness. I understand that the purpose of the program is to improve, develop and maintain cardio respiratory fitness, muscular strength and endurance. I understand that I am responsible for monitoring my own condition throughout the exercise program.
I acknowledge that participating in this Proactivity Program may involve real risks including but not limited to serious injury or even death from various causes including over-exertion, dehydration and accidents with other participants. I voluntarily assume all risks associated with my participation in the Proactivity Program or any activity associated with it. Further, and without limitation, to the extent the Proactivity Program is conducted outdoors, I also accept full responsibility for any and all risks associated with the prevailing weather conditions and air quality. By participating in the Proactivity Program I represent to Proactivity that I have monitored the weather and air quality conditions and accept any and all risks posed by such conditions.
I, the undersigned, in consideration of and as a condition of acceptance of my participation in the Proactivity Program for myself, my executors, administrators, heirs, next of kin, successors and assigns, release Proactivity Pty Ltd and each of its officers, employees, contractors, agents and any person or other body directly or indirectly associated with the Proactivity Program (collectively the ‘Released Persons’), from all claims, demands and proceedings arising out of or in connection with my participation in the Proactivity Program. I fully indemnify each of the Released Persons against any and all liability (including acts of negligence to the fullest extent permitted by law) whatsoever and howsoever caused arising as a result of or in connection with my participation in the Proactivity Program including any loss whatsoever of personal property or otherwise.
I consent to my details being disclosed to parties necessary in the conduct of the Proactivity Program and any medical officials during treatment.
Declaration for minors - If you are under 18 years at the time of participating in the Proactivity Program, this declaration MUST be accepted and signed by your parent or guardian. I certify that I am the parent/guardian of (the ‘minor’) who will be participating in the Proactivity Program. In consideration of Proactivity Pty Ltd accepting the minor’s application to participate in the Proactivity Program, I agree to indemnify and will keep indemnified Proactivity Pty Ltd in respect of any and all losses they or any of the Released Persons may suffer as a consequence of any claim(s) by the minor and to the same extent as any other participant indemnifies the Released Persons pursuant to clause 4 above.

Signature of Participant, or Participant's Guardian(Required)

Signed On Date(Required)

Name of Parent / Guardian (if applicable)

First Name Last Name