FUNCTIONAL PATTERNS NEW JERSEY LLC
PARTICIPANT AGREEMENT, INFORMED CONSENT AND RELEASE OF LIABILITY
For adult participants and parents/guardians of minor participants
PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE.
1. PARTICIPANT INFORMATION
| Participant Name | Date of Birth |
| Address | City / State / ZIP |
| Phone | Email |
| Emergency Contact | Relationship |
| Emergency Phone |
2. NATURE OF SERVICES AND VOLUNTARY PARTICIPATION
I voluntarily choose to participate in services offered by Functional Patterns New Jersey LLC ("FPNJ"). Services may include fitness assessments, posture and movement observation, resistance exercise, conditioning, walking and running mechanics, balance and coordination work, mobility exercises, throwing or rotational drills, jumping or landing drills, breathing exercises, use of specialized equipment, group training, youth training, and other physical activities selected by FPNJ personnel. I understand that activities will be adjusted based on coaching judgment, but no activity can be made completely risk free.
3. HEALTH DISCLOSURE AND MEDICAL CLEARANCE
I represent that the information I provide in the intake form is complete and accurate to the best of my knowledge. I will promptly tell FPNJ about any change in my health, pain, symptoms, medication, pregnancy status, medical restriction, injury, surgery, or diagnosis that may affect participation. I understand that FPNJ personnel are not physicians and do not diagnose or treat disease or injury. I am responsible for obtaining medical clearance when appropriate or requested. I will stop an activity and immediately report unusual pain, dizziness, faintness, shortness of breath, chest discomfort, loss of coordination, numbness, or other concerning symptoms.
Participant Initials:
4. ACKNOWLEDGMENT AND ASSUMPTION OF RISK
I understand that physical training and use of exercise equipment involve inherent and other risks, both known and unknown. Risks may include, without limitation: slips and falls; equipment failure or misuse; collisions; muscle soreness; strains; sprains; tendon or ligament injury; joint, neck, back, head, or spinal injury; fractures; concussion; heat illness; allergic reaction; abnormal blood pressure; fainting; cardiac event; aggravation of an existing condition; disability; property damage; and, in rare circumstances, death. Risks may arise from my actions, the actions of others, the condition of the premises or equipment, or ordinary negligence. I knowingly and voluntarily accept and assume all risks of participation, including risks that are not specifically described in this agreement.
Participant Initials:
5. RELEASE, WAIVER AND COVENANT NOT TO SUE
TO THE FULLEST EXTENT PERMITTED BY NEW JERSEY LAW, I RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Functional Patterns New Jersey LLC; its owners, members, managers, employees, independent contractors, coaches, instructors, agents, volunteers, successors, and assigns; and the owners, landlords, and operators of any premises used for services (collectively, the "Released Parties") for claims, demands, causes of action, damages, losses, or expenses arising from or related to my participation, presence at the facility, or use of equipment, including claims based on the ordinary negligence of a Released Party. This release does not apply to gross negligence, reckless conduct, intentional misconduct, or any liability that cannot lawfully be waived.
Participant Initials:
6. INDEMNIFICATION
To the fullest extent permitted by law, I agree to indemnify and hold harmless the Released Parties from claims, losses, liabilities, or expenses arising from my own acts or omissions, my violation of facility rules, or inaccurate or incomplete health information I provided. This provision does not require me to indemnify a Released Party for that party's gross negligence, reckless conduct, or intentional misconduct.
7. EMERGENCY CARE AUTHORIZATION
If I become ill or injured and cannot provide instructions, I authorize FPNJ personnel to contact emergency services and my emergency contact and to arrange reasonable emergency care. I understand FPNJ does not guarantee that personnel trained in first aid or CPR will be present. I am responsible for costs of medical care, transportation, or treatment not covered by insurance. This authorization does not create a duty for FPNJ to provide medical treatment.
8. FACILITY RULES, PERSONAL PROPERTY AND CONDUCT
I agree to follow coaching instructions and posted or communicated safety rules; use equipment only as directed; wear suitable clothing and footwear; avoid participation while impaired by alcohol, recreational drugs, or any substance that makes participation unsafe; and treat staff and other participants respectfully. FPNJ may pause or end a session or terminate access when it reasonably believes conduct is unsafe, disruptive, abusive, or inconsistent with facility rules. I am responsible for my personal property, and FPNJ is not responsible for loss, theft, or damage except where required by law.
9. MANUAL CUEING AND PHYSICAL CONTACT
I understand that coaching may involve brief, professional physical contact or manual cueing to help communicate positioning, alignment, direction, or safety. I may decline or stop physical contact at any time by telling the coach. Declining physical contact will not prevent me from receiving coaching, although some activities may need to be modified.
Manual cueing preference:
10. OPTIONAL PHOTO, VIDEO AND TESTIMONIAL AUTHORIZATION
Media consent is optional and is not a condition of receiving services. Select one option below. A selection may be revoked prospectively by written notice, but revocation will not require removal of material already published or distributed before FPNJ received the notice.
Participant/Parent Initials:
11. MINORS
For a participant under 18, the parent or legal guardian signing below represents that they have authority to sign for the minor, consents to the minor's participation, accepts the risks on the minor's behalf to the fullest extent permitted by law, authorizes emergency care as stated above, and agrees to be bound by this agreement in their individual capacity. The minor participant should sign when developmentally appropriate.
12. GENERAL TERMS
This agreement is governed by New Jersey law. Any provision found unenforceable will be limited or severed to the minimum extent necessary, and the remaining provisions will remain effective. This agreement contains the entire agreement regarding risk, release, and participation and may be changed only in a writing signed by FPNJ and the participant or parent/guardian. It applies to current and future visits and services until replaced or revoked in writing, but FPNJ may request a new agreement periodically. A photocopy or electronic copy and an electronic signature may be treated as an original to the extent permitted by law.
13. ACKNOWLEDGMENT AND SIGNATURES
I HAVE READ THIS AGREEMENT, UNDERSTAND IT, HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS, AND SIGN IT VOLUNTARILY. I UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL LEGAL RIGHTS.
| Participant/Client Printed Name | Date of Birth |
| Participant/Client Signature | Date |
| Parent/Guardian Printed Name | Relationship |
| Parent/Guardian Signature | Date |
| FPNJ Representative (optional) | Date |
Optional combat-sports addendum: Complete only when the participant will engage in boxing, kickboxing, wrestling, judo, Brazilian jiu-jitsu, sparring, or other contact/combat-sport activity.
OPTIONAL COMBAT AND CONTACT ACTIVITY ADDENDUM
I understand that combat and contact activities may involve intentional or accidental bodily contact, takedowns, throws, grappling, striking drills, falls, collisions, and rapidly changing force. Additional risks include cuts, bruises, dental injury, eye injury, dislocation, concussion, choking or strangulation injury, loss of consciousness, internal injury, neurological injury, paralysis, and death. I voluntarily assume these additional risks and agree that Sections 5 through 12 above apply to these activities. I will use required protective equipment, follow rules, disclose relevant symptoms, and immediately stop if directed.
| Participant/Parent Initials | Date |