NERD Gym, 4181 S. De Frame St, Morrison CO 80465
Phone: (720) 326-3989
NERD Gym Membership Release Form
Member Details
Name: ___________________________________________ Date of Birth: __________________
Address: ____________________________________________________________
City: _____________ State: _____________ Zip: _________
Phone: _______________________________________ Email: ______________________________
Start of Membership: ___________ Membership Program Type: Monthly Quarterly Annually
Physical Conditions
To ensure safety and a successful program, it is necessary to know any physical conditions that may require a
change to the program. Please note any injuries or surgeries that should be considered for your training program.
Year: ______ Details: ________________________________________________________________
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Year: ______ Details: ________________________________________________________________
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Year: ______ Details: ________________________________________________________________
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Medical Conditions
Please note any medical conditions that could prevent certain activities or require adjustments to the training
program (i.e. lifting restrictions, mobility limitations, etc.). Such restrictions are provided by a physician.
Condition: ______________ Restrictions: _________________________________________________
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Condition: ______________ Restrictions: _________________________________________________
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Condition: ______________ Restrictions: _________________________________________________
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Emergency Contact(s)
Name: ____________________________________________ Relationship: __________________
Phone: ___________________________________________
Name: ____________________________________________ Relationship: __________________
Phone: ___________________________________________
Liability Waiver
I, __________________________, acknowledge that I am responsible for my own health and physical
condition. Also, I understand that my participation in this exercise program could cause injury based on
performing these activities. While the fitness trainer will teach me proper techniques to prevent injury, I
release them from any liability for these injuries.
No fitness trainer or fellow members are liable for any accidental injuries or illness which I may incur as
a result of participating in any program from NERD Gym. I assume all risk connected to all programs
and consent to participate.
It is my responsibility to disclose any physical limitations, disabilities, or related restrictions that may
affect my ability to participate in the NERD Gym program. This includes any changes that may occur
throughout the program.
By signing this form, I am agreeing to participate in the program selected by the fitness trainer at NERD
Gym. For any members 18 or younger, I ______________________________ (parent or guardian),
agree to the above requirements.
Member or Parent Signature: _______________________________________________
Date: ____________