Xtreme Liability Waiver

Informed Consent Agreement 

Program Objectives 

I understand that my physical fitness program is individually tailored to meet the goals and objectives agreed upon by my personal trainer and myself. I understand, however, that my personal trainer cannot guarantee that I will accomplish the goals that I establish. My program goals include (please initial all that apply):

___ Cardiovascular improvement            ___ Improved muscular endurance

___ Increased strength      ___ Improved flexibility

___ Decreased body fat      ___ Weight loss

___ Other (list)__________________________________________________________________


Description of the Exercise Program 

I understand that my exercise program will involve participation in a number of types of fitness activities. These activities will vary depending upon my established objectives, but will probably include:

1) Aerobic activities including, but not limited to, the use of treadmills, stationary bicycles, step machines, rowing machines, and running track;
2)Muscular endurance and strength building exercises including, but not limited to, the use of free weights, weight machines, calisthenics, and other exercise apparatus;
3)Other activities selected by my personal trainer and agreed upon by me; and
4)Selected physical fitness and body composition tests.

Description of Potential Risks 

My personal trainer has explained that no exercise program is without inherent risks and that, regardless of the care taken by my personal trainer, he (or she) cannot guarantee my personal safety.

For example, when one induces cardiovascular stress through activity, injuries can range from occasional minor injury (e.g., pulled muscles, muscle soreness) to infrequent serious injury (e.g., heart attack, stroke, or other cardiovascular accidents) to the very rare catastrophic incident (e.g., death, paralysis). Likewise, I know that engaging in muscular endurance, strength building, and other fitness activities occasionally results in minor injuries(e.g., bruises, musculo-skeletal strains and sprains), infrequently, more serious injuries (e.g., muscle tears, herniated disks, torn rotator cuffs), and very rarely, catastrophic injury (e.g., death, paralysis).

I realize that when participating in any exercises or conditioning activity, there is always a possibility that minor injuries, major injuries, or catastrophic injury/death may occur.

Description of Potential Benefits 

I understand that a regular exercise program has been shown to have definite benefits to general health and well-being. I know that some of the physiological benefits of a regular exercise program can include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement in cardiovascular function, reduction in risk of heart disease, improved strength and muscular endurance, improved posture, and improved flexibility. I further understand that regular exercise can have psychological benefits, often improving one’s outlook and feeling of well-being, as well as relieving tension and stress.

Client Responsibilities 

I understand that it is my responsibility to:

1) Fully disclose any health issues (including diabetes, heart problems, seizures, and asthma) or medications that are relevant to participation in a strenuous exercise program;
2) Inform the trainer if there are activities with which I do not feel comfortable;
3) Cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea, difficulty breathing, apparent injury) during the exercise program; and
4) Clear my participation with my physician.

Client Acknowledgements 

In agreeing to this exercise program, I, the client:

• acknowledge that my participation is completely voluntary.

• understand the potential physical risks involved in the exercise program and believe that the potential benefits outweigh those risks.

• give consent to certain physical touching that may be necessary to ensure proper technique and body alignment.

• understand that the achievement of health or fitness goals cannot be guaranteed.

• have had a voice in planning and approving the activities selected for my exercise program.

• have been able to ask questions regarding any concerns I might have, and have had those questions answered to my satisfaction.

• am in good physical condition, have no impairment which might prevent my participation in such activities, and have been advised to consult a physician prior to beginning this program

• have been advised to cease exercise immediately if I experience unusual discomfort and feel the need to stop.


I have read and understand the above agreement. I have been made fully aware of and understand the potential risks involved in this physical fitness program. I hereby consent to those risks and am freely and voluntarily participating in this program. Finally, I am freely signing this agreement.

Cardiovascular improvementImproved muscular enduranceIncreased strengthImproved flexibilityDecreased body fatWeight lossOther (list)

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