Speed & Agility Training Register
Registration:
To sign up for a RPL FAST training session please print out the Youth Waiver Form below and return to Ray Luthi by either email or US Post.
Email: ray.luthi@gmail.com
RPL FAST
ATT: Ray Luthi
19 Coursen Way
Madison, NJ 07940
For a printable version of the Youth Waiver Form select the link below:
Youth Athlete Medical and Waiver Form
RPL Fitness: Agility, Speed Training, Inc.
Name of Athlete: ______________________________ Age:______ Height:________ ft Weight:_____lbs.
Name of Parent/Guardian:_________________________________________
Parent Cell Phone:___________________ Home Phone:____________________ Work Phone:_________________
Address:______________________________________________________________________________________
Emergency Contact Name/Phone (If different than above):______________________________________________
Name of Physician/Phone:________________________________________________________________________
Medical History
Is there a known history of:
A. Pre existing injury currently under treatment? Y N
B. Birth deformities (one eye, one kidney, etc)? Y N
C. Medical conditions currently under treatment? Y N
D. Is the athlete currently taking any medication? Y N
E. Fractures or other disability type injuries? Y N
F. Allergies (drug, food, asthma, etc.)? Y N
Note: if you have a prescription for an epinephrine pen or
inhaler please ensure your athlete has it!
G. Mental disorders or convulsions? Y N
Please explain any above yes in detail:
I acknowledge that training for and/or participating in any physical activity such as, but not limited to: team sports, cycling, swimming, running, strength training, general fitness activities or any other endurance sporting event is an extreme test of physical and mental limits and that such training and/or participation poses potential risks of serious bodily injury, death, or property damage. The assumption of risk in these cases and others is fully mine, the undersigned. I have provided RPL Fitness: Agility, Speed Training, Inc. with all information which in any way relates to or that could affect my physical and mental health and attest that I (my child) am(is) in good health and my physical condition has been verified by a licensed medical doctor.
Furthermore, in return for my participation in this program, I on behalf of myself and my heirs and/or executors hereby:
a)WAIVE, RELEASE, and DISCHARGE RPL Fitness: Agility, Speed Training, Inc., its affiliates, officers, directors, administrators, employees, consultants, coaches, contractors, and agents from any claims, costs or liabilities for personal injury, illness, death or damages of any kind which I may have now, or at any time in the future, resulting from participation in this or any other program;
b) AGREE NOT TO SUE any of the persons or entities mentioned above for any claims, costs or liabilities that I have waived, released or discharged herein;
c) INDEMNIFY, DEFEND, and HOLD HARMLESS, the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions, their actions (including negligent ones), or lack of actions.
I understand that RPL Fitness: Agility, Speed Training, Inc. is/are not (a) registered dietician(s), and in no way does any discussion or information of supplements or nutrition constitute advice or a prescription of any kind. All discussions/messages regarding food and nutritional supplements are merely anecdotal.
I grant the right to use my name, image, personal information in any photographic or written record for any purpose if obtained with prior consent.
I affirm that I am eighteen (18) years of age or older, I have read this document and understand its contents. If not 18, my parent or guardian has read this document and understands its contents.
Athlete Name (Print)____________________________________________________
Parent/Guardian Name if under 18 (Print)_____________________________________________
