Pre-Exercise Health Screening & Activity Waiver
Business: Shibusa Jiu Jitsu Pty Ltd (“the Activity Provider”)
Part 1: Electronic Signature Consent
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with the Activity Provider for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
Part 2: Pre-Exercise Health Questionnaire (Mandatory)
The ACT Fitness Industry Code of Practice 2009 requires all members to complete this screening.
Please answer the following questions truthfully:
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Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? NO YES
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Do you experience unexplained pains or discomfort in your chest during or after physical exercise? NO YES
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Do you ever feel faint, dizzy, or lose balance during physical activity? NO YES
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Have you had an asthma attack requiring medical attention in the last 12 months? NO YES
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If you have diabetes (Type 1 or 2), have you had trouble controlling your blood glucose in the last 3 months? NO YES
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Do you have any diagnosed muscle, joint, or bone problems that could be made worse by participating in Jiu-Jitsu? NO YES
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Are you pregnant or have you given birth in the past 3 months? NO YES
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Do you have any other medical conditions or are you taking medication that may make it dangerous for you to participate? NO YES
Mandatory Health Declaration (Only if you answered "YES" to any question above)
If you answered YES to any of the questions above, the Activity Provider cannot supply fitness services to you unless you provide evidence that you are not at risk.
Please check ONE of the options below:
Part 3: Activity Waiver & Release of Liability
1. Details of Activity The Participant will be participating in Brazilian Jiu Jitsu (the "Activity") provided by Shibusa Jiu Jitsu Pty Ltd (the "Activity Provider").
2. Consideration Being of lawful age and in consideration of being permitted to participate in the Activity, the Participant releases and forever discharges the Activity Provider, its owners, directors, officers, employees, agents, assigns, legal representatives, and successors from all manner of actions, causes of action, debts, accounts, bonds, contracts, claims, and demands for or by reason of any injury to person or property, including injury resulting in the death of the Participant, which has been or may be sustained as a consequence of the Participant's participation in the Activity, and notwithstanding that such damage, loss, or injury may have been caused solely or partly by the negligence of the Activity Provider. The Participant understands that they would not be permitted to participate in the Activity unless they signed this Waiver.
3. Inherent Risk & Physical Condition The Participant acknowledges that participating in physical activities at the Activity Provider’s facility and using its equipment carries inherent risks of physical injury, including but not limited to broken bones, soft tissue injuries, joint injuries, permanent disability, or death. These may occur as a result of training, slipping on flooring, or collision with equipment or other members. The Participant represents that they are in good physical condition and are unaware of any medical or other reason why they should not engage in the Activity. They acknowledge that Activity Provider instructors are not medically trained and are therefore not qualified to assess whether a Participant is in good physical condition.
4. Infections & Illness The Participant shall not use the Activity Provider’s facilities and/or equipment or participate in any activities while suffering from any infections or contagious illness, disease, or other ailment (including but not limited to open cuts, abrasions, ringworm, open sores, or minor infections) where there is a risk, regardless of size, to other members, guests, and instructors.
5. Drugs & Alcohol No person under the influence of drugs or alcohol is permitted to use Activity Provider equipment, facilities, or participate in physical activities.
6. Pregnancy Should the Participant suspect pregnancy or become pregnant, it is their responsibility to notify the Activity Provider immediately. The Activity Provider will require a medical letter authorising continued training and detailing any specific requirements or restrictions from a general practitioner.
7. First Aid The Participant agrees that the Activity Provider’s instructors or volunteers may provide any first aid treatment deemed necessary in the event of an emergency.
8. Limitation of Liability & Indemnity To the fullest extent permitted by applicable law, the Activity Provider, its related entities, employees, and agents shall not be liable for any loss or damage to property, bodily injuries, illness, or death sustained by the Participant, their guests, or third parties within the facilities. The Participant hereby releases and forever discharges the Activity Provider from all actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs and expenses however arising from or in connection with involvement in the Activity or being on the premises. The Participant agrees to fully indemnify the Activity Provider against any claims, liabilities, expenses, damages, or losses arising from any breach of these terms or any act, omission, or negligence by the Participant or their guest.
9. Concurrent Release The Participant acknowledges that this Waiver is given with the express intention of effecting the extinguishment of certain obligations owed to the Participant by the Activity Provider, and with the intention of binding the Participant's spouse, heirs, executors, administrators, legal representatives, and assigns.
10. Governing Law This Waiver is governed by and construed in accordance with the laws of the Australian Capital Territory.
Part 4: Final Settlement
Full and Final Settlement The Participant acknowledges and agrees that:
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The Activity Provider has given them sufficient time to carefully read this Waiver.
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The Participant has had the opportunity to seek independent legal advice before signing.
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The Participant fully understands the risks and claims being waived.
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The Participant is freely and voluntarily executing this Waiver and is permanently waiving their right to sue or make claims against the Activity Provider for any injury or loss sustained.
IN WITNESS WHEREOF the Participant (or Parent/Guardian if the Participant is under 18 years of age) has duly affixed their signature on {sign_date}.
