General Information

First Name*

Last Name*

Date of Birth*Please enter a valid date (mm/dd/yyyy)

Email*Please enter a valid email

Phone*

Gender*

Male

Female

Other

Address*

City*

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Zip*

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How did you hear about Burn?*

Referred By:

Emergency Contact Information

Emergency Contact Name*

Relationship To You*

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Legal Agreement Regarding Activities, Events, and Services

WAIVER AND RELEASE

In consideration of being permitted to receive and participate in Persava Partners, LLC d/b/a Burn BootCamp ("Company") personal and group training services and programs ("Program(s)"), you or yourparent(s) and/or legal guardian(s) if you are a minor, agree to the following:

1. You understand that there are risks and dangers associated with participating in physical exerciseand activities which may result in accident, injury, death or other adverse effects to your health or medical conditions.You have sole responsibility for your (or your minor child's) physical and mental health.

2. You assume all risks of participating in the Programs. You assume the risk of any injury, damage, orloss that you or your minor child may sustain as a result of participating in the Programs provided by the Company.You hereby waive, discharge, indemnify, and release the Company, its owners, managers, directors, officers, agents,trainers, consultants, contractors, and employees from and against any and all liabilities, injuries, death, loss, claims,suits, damages, or demands, attorney fees, costs, and expenses of any nature, which you now have or may have in thefuture, arising from or pertaining to your or your minor child's participation in the Programs provided by the Company.

3. You understand that Company does not and will not provide any medical advice regarding yourphysical health or medical conditions. As part of the Programs, the Company's trainers may provide nutrition relatedrecommendations which should not be construed as medical advice. You agree not to rely on information provided byCompany as an alternative to medical advice from your doctor or other professional healthcare provider. You agree toaddress any specific questions about any medical or health related matters to your doctor or professional healthcareprovider. You represent that you are in good health and have obtained all medical approvals necessary to participate inthe Programs.

4. You hereby waive, discharge, indemnify, and release the Company, its owners, managers, directors,officers, agents, trainers, consultants, contractors, and employees from and against any and all liabilities, injuries,death, loss, claims, suits, damages, or demands, attorney fees, costs, and expenses of any nature, which you nowhave or may have in the future, arising from or pertaining to your or your minor child's participation in the Programsprovided by the Company. You agree that this Waiver and Release is binding on you and your heirs, successors,assigns. You further understand this Waiver and Release shall be governed under the laws of the State of Wisconsin.

5. By signing below, you hereby grant the Company permission and right to use your image in allforms (video, recordings, photographs, etc....) and media (social media, websites, print, television, etc...), without anyrestrictions as to changes or alterations, for advertising, trade, promotion, exhibition, or any other lawful purpose. Youhereby waive and release the Company, its officers, directors, members, managers, employees, agents, contractors,and shareholders, from any and all claims, liabilities, invasion of privacy claims, or damages arising from or pertainingto the use of my image by the Company for the purposes stated herein.

6. You agree that if any provision of this Waiver and Release is held to be illegal, invalid orunenforceable, then such provision will be fully severable and the remaining provisions contained herein will remain infull force and effect and will not be affected by the illegal, invalid or unenforceable provision. You agree that you havebeen provided with reasonable opportunity to consult with legal counsel regarding the terms of this Waiver andRelease.

7. There is a risk that you may become exposed to COVID-19 while working out at our facility. Youhereby acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you may be exposed to orinfected by COVID-19 while working out at our facility. You hereby release, covenant not to sue, discharge, and holdharmless Persava Partners, LLC , its shareholders, directors, members, officers, employees, agents, andrepresentatives, from and against any and all liabilities, claims, suits, injuries, infections, death, actions, damages,costs or expenses of any kind arising out of or relating thereto.

I HAVE READ THIS WAIVER AND RELEASE, FULLY UNDERSTAND ITS TERMS AND SIGN IT FREELY ANDVOLUNTARILY, AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITYOF THE COMPANY, ITS OWNERS, MEMBERS, MANAGERS, EMPLOYEES, AND TRAINERS, TO THE GREATESTEXTENT ALLOWED UNDER WISCONSIN LAW.

04/24/2024

Burn Boot Camp Client PAR-Q and MindBody Profile Set Up

Please answer each question accurately and honestly; for each Yes answer, please briefly explain

1. Has any healthcare professional ever said that you have a heart condition and that you should only engage in physical activity as recommended by a doctor?*

Yes

No

Please explain:

2. Do you feel pain in your chest when you engage in physical activity?*

Yes

No

Please explain:

3. In the past month, have you had any chest pain when you were not doing physical activity? *

Yes

No

Please explain:

4. Do you lose your balance or ever lose consciousness, even if just briefly?*

Yes

No

Please explain:

5. Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity?*

Yes

No

If yes, please explain:

6. Is your doctor currently prescribing medications or any treatment regimen related to your blood pressure or heart condition?*

Yes

No

Please explain:

7. Do you know of any other reason why you should not engage in physical activity?*

Yes

No

Please explain:

If you answered YES to one or more questions, consult with your doctor BEFORE you start becoming more physically active or BEFORE you have a fitness appraisal.Tell your doctor about the PAR - Q and to which questions you answered YES.You may be able to do any activity you want– as long as you start slowly and build up gradually, or, you may need to restrict your activities to those that are safe for you.Talk with your doctor about the kinds of activities you wish to participate in and follow his / her advice.Find out which programs are safe and helpful for you.

If you accurately answered NO to all PAR - Q questions , you likely can start becoming much more physically active– begin slowly and build up gradually.This is the safest and easiest way to go.Take part in a Focus Meeting– this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.It is also highly recommended that you have your blood pressure evaluated.If your reading is over 144 / 94, talk with your doctor before you start becoming much more physically active.

However, regardless of how you answered the above questions and what may be true for most people, each of us is unique and you should always err on the side of caution with regard to physical safety , which may include seeking medical evaluations.

Please note that if your health changes so that you then answer YES to any of the above questions, you must tell your Burn Trainer and seek a medical evaluation from a physician, including advice as to future physical activities both in relation to Burn and otherwise. You and we will always want to make any reasonable modifications possible to your physical activity plan.

PLEASE COMPLETE THE FOLLOWING QUESTIONS IF YOU WERE PREGNANT WITHIN THE LAST YEAR:

In the past year, have you had a pregnancy/birth of a baby?

Yes

No

If you are less than 6 weeks post - partum please provide a doctor's clearance note.

Type of delivery?

Any physical challenges that occurred?

Breastfeeding?

Diastasis Recti / Incontinence / Pelvic Organ Prolapse?

Delay becoming much more active if you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better; or if you are or may be pregnant – talk to your doctor before you start becoming more active.