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Bring-a-Friend Week — January 13-25, 2025

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Indicate the training date and time
Write the Member's name that referred you

Registration

No refunds. Read policies. NOTE: Please be sure you complete your registration. If you did not receive an email confirmation, you're registration did not go through.

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Registration*

Please indicate what you are registering for:

Free Trial Class

Drop In

CrossFit

Beginners CrossFit

All Levels Fitness

Cynergy BUILD

Cynergy LIVE

Cynergy Kids

Youth CrossFIt

Boot Camp

First Responder Fridays

CrossFit Experience*

Do you have any CrossFit experience?

Yes

CrossFit Experience

Please let us know where you've done CrossFit and for how long.

NOTE: The Cynergy Kids program starts back September 5th!

Cynergy Kids Training Days*

Mon @ 4PM & Thu @ 6:30PM

Mon @ 4PM Only

Thu @ 6:30PM Only

to continue your registration for Cynergy's LIVE Program.

to continue your registration for Cynergy's BUILD Program.

to continue your registration for Cynergy's Youth CrossFit program.

to continue your registration for Cynergy's Teens Strength Program.

to continue your registration for Cynergy's Boot Camp program.

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Employment*

Please indicate where you work or from where you are retired.

CrossFit Experience*

Beginner: Little to no CrossFit experience

Intermediate: Trained with another CrossFit gym for less than 6 months

Experienced: Trained with another CrossFit gym for more than 6 months

NOTE: Because you are new to CrossFit you will be required to go through our Beginners CrossFit class. Please change your Registration above to "Beginners CrossFit" and complete the registration form. Thank you.

NOTE: Because you are relatively new to CrossFit, we will assess your readiness for our group classes. If we feel you need additional training, you will need to go through our Beginners CrossFit class.

Are you registering for a child?*

Yes

Athlete's Name*

(Please indicate child's name here if you are registering your child.)

First Last

Athlete's Email*

Enter Email Confirm Email

Parents Name*

Parents Email*

Enter Email Confirm Email

Birth Date*

MM slash DD slash YYYY

Age*

Address*

Street Address City State ZIP Code

Phone*

Training Date & Time*

Please indicate the date and time you will be joining us. Please review our schedule for available times.

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Bring-a-Friend Week*

Please indicate what days you'll be joining us!

Tuesday, Jan 23, 2024 AM Class

Tuesday, Jan 23, 2024 PM Class

Thursday, Jan 25, 2024 AM Class

Thursday, Jan 25, 2024 PM Class

Saturday, Jan 27, 2024

First Responder, Nurse, Military?*

Please indicate whether you are a first responder, nurse or military; select all that apply.

Firefighter

Police

Nurse

EMT

Paramedic

Military

None

Primary Fitness / Health Goal*

lose weight

gain weight

gain muscle / improve strength

improve overall health

reduce / eliminate medications

other

Other*

Goals*

Please let us know what you would like to achieve or accomplish with your training?

Nutrition Program*

Are you interested in learning more about our personalized nutrition program?

Yes

Payment*

You are required to bring a completed copy of Cynergy’s Automatic Debit Payment form and a voided check with you on your first day.

I understand.

How did you hear about us?*

Cynergy CrossFit Member

Friend

CrossFit Affiliate Finder

Online Search

Facebook

Instagram

Twitter

Drive By

Repeat

Other

Member's Name*

Friend's Name

Waiver & Medical History*

If you have already completed the Waiver and Medical History form in the last 12 months, please indicate below.

No, I have not completed these forms in the past year.

Yes, I have completed these forms in the past year.

Medical History

Physical activity should not pose any problem or hazard to the majority of people. The following questions are designed to identify the small number of adults for whom physical activity might be inappropriate or those who should seek medical advice prior to initiating a fitness program or other change in their physical activity levels.

Are you accustomed to vigorous exercise?*

Yes

Have you ever been diagnosed with Type I or Type II Diabetes?*

Yes

Are you pregnant, or have you been pregnant within the last 3 months?*

Yes

Have you had any major or minor surgery in the past 3 months?*

Yes

If yes, please describe.*

Have you ever seen a chiropractor or physical therapist for any condition?*

Yes

If yes, please describe.*

Have you been hospitalized in the last 2 years?*

Yes

If yes, when and for what reason?*

Do you have shortness of breath or labored breathing, with or without pain?*

Yes

If yes, describe under what conditions.*

Do you experience unexplained heart palpitations or been diagnosed with a heart murmur or irregular heartbeat?*

Yes

Have you ever been diagnosed with high blood pressure?*

Yes

If yes, when?*

Do you currently smoke?*

Yes

If yes, how many cigarettes per day?*

Have you ever smoked?*

Yes

If yes, how long ago did you quit?*

Waiver Release

I have volunteered to participate in a fitness program provided to me by Cynergy CrossFit which may include, but may not be limited to, resistance training and aerobic or cardiovascular exercise. In consideration of Trainer’s agreement to instruct and train me, I do here now and forever release and discharge and hereby hold harmless Trainer and her respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT BELONGING TO TRAINER OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT; (3) AND/OR NEGLIGENT INSTRUCTION OR SUPERVISION.

I have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity. I also have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved.

I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death. I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed.

If I have chosen not to obtain a physician’s consent prior to beginning this fitness program with Trainer, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST TRAINER FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.

Cynergy CrossFit may use photography and video during regular classes and training events. These photos may be used in email campaigns or advertisements. If you DO NOT want your image to appear in print or in video, please include a note in the comments section at the bottom of this form.

This form is an important legal document that explains the risks you are assuming by beginning an exercise program. It is critical that you have read and understand this document completely. If you do not understand any part of this document, it is your ultimate responsibility to ask for clarification prior to signing it.

Waiver Release Approval*

I have read and understand the Waiver Release information.

Additional Comments or Information

Phone

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