PERTH CAMPSREGISTRATION FORMPLEASE COMPLETE THE REGISTRATION FORM BELOW. PAY NOW Name * First Name Last Name Email * Contact Phone Number * Date of birth * MM DD YYYY WHICH CAMP ARE YOU REGISTERING FOR? * For Cadre Camp registrations, please email a passport size photo of yourself to info@themillgym.com. CADRE CHAOS HAVOC GENDER * MALE FEMALE NON-SPECIFIC OTHER T-SHIRT SIZE PLEASE SELECT YOUR T-SHIRT SIZE: MALE - S MALE - M MALE - L MALE - XL FEMALE - S FEMALE - M FEMALE - L FEMALE - XL PANTS SIZE PLEASE SELECT YOUR WAISTBAND (INCHES) 28 30 32 34 36 38 OTHER, PLEASE SPECIFY BELOW OTHER PLEASE SPECIFY YOUR PANTS SIZE IF NOT PROVIDED ABOVE. Next Emergency Contact (NEC) * WHO CAN WE CALL IN THE EVENT OF AN EMERGENCY? NEC PHONE NUMBER * NEC RELATIONSHIP * SPOUSE PARTNER SIBLING FRIEND OTHER Do you have any of the following medical conditions? * WE RECOMMEND THAT ALL PROSPECTIVE MEMBERS UNDERTAKE A COMPLETE MEDICAL ASSESSMENT PRIOR TO COMMENCING TRAINING WITH US. HIGH/LOW BLOOD PRESSURE HEART CONDITION JOINT PAIN OR WEAKNESS EPILEPSY ASTHMA CHRONIC NECK OR BACK PAIN DIABETES KIDNEY DISEASE OTHER NONE OF THE ABOVE IF YOU TICKED 'OTHER' ABOVE, PLEASE SPECIFY. ARE YOU CURRENTLY TAKING ANY MEDICATIONS? * YES NO IF 'YES', WHICH MEDICATION? You will be permitted to take prescription medications with you on the camp. DO YOU HAVE ANY ALLERGIES? * YES NO UNSURE IF 'YES', WHICH ALLERGY? DO YOU SMOKE? * YES NO IF 'YES' HOW MANY CIGARETTES DO YOU SMOKE PER WEEK? DO YOU DRINK ALCOHOLIC BEVERAGES? * YES NO IF 'YES', HOW MANY DRINKS PER WEEK ON AVERAGE? LESS THAN 6 STANDARD DRINKS PER WEEK MORE THAN 6 STANDARD DRINKS PER WEEK IMPORTANT WAIVER, RELEASE AND INDEMNITY * I, AS NAMED ABOVE, MAKE THE FOLLOWING REPRESENTATIONS:: • I HAVE NO IMPAIRMENTS, ILLNESSES OR CONDITIONS THAT MIGHT ENDANGER ME OR OTHERS WHILST TRAINING AT THE MILL GYM. • I WILL DISCLOSE ANY IMPAIRMENTS, ILLNESSES OR CONDITIONS THAT MIGHT AFFECT MY ABILITY TO TRAIN AT THE MILL GYM TO A TRAINER BEFORE UNDERTAKING ANY TRAINING. • I UNDERSTAND THAT TRAINING AT THE MILL GYM IS EXTREMELY MENTALLY AND PHYSICALLY DEMANDING AND INVOLVES SIGNIFICANT RISKS OF INJURY TO ME AND TO THOSE TRAINING AROUND ME WHICH EXCEED THE RISKS COMMONLY ACCEPTED IN OTHER SPORTS AND PHYSICAL TRAINING ENVIRONMENTS. • I UNDERSTAND THAT ACCIDENTS AND INJURIES RESULTING FROM FALLS, DROPPED WEIGHTS OR EQUIPMENT OR FAILED EQUIPMENT OR OTHER CAUSES MAY HAPPEN WITHOUT FAULT OR NEGLIGENCE ON ANYONE’S PART AND THAT SERIOUS INJURY OR DEATH MAY RESULT. • I HAVE READ THIS FORM CAREFULLY AND UNDERSTAND THAT BY SELECTING 'I AGREE', I AM RELEASING VALUABLE LEGAL RIGHTS THAT I MIGHT OTHERWISE HAVE AND THAT I INDEMNIFY THE MILL GYM FROM THE CONSEQUENCES OF MY NEGLIGENT OR INTENTIONAL ACTS THAT CAUSE DAMAGE OR INJURY. • I WILLINGLY ASSUME FULL RESPONSIBILITY FOR THE RISKS TO WHICH I WILL BE EXPOSED IN TRAINING AT THE MILL GYM AND IN PARTICIPATING IN ACTIVITIES ORGANISED BY THE MILL GYM. RELEASE: IN CONSIDERATION OF THE FOREGOING, I, FOR MYSELF, MY HEIRS, EXECUTORS, ADMINISTRATORS, PERSONAL REPRESENTATIVES, SUCCESSORS AND ASSIGNS, WAIVE AND RELEASE ANY AND ALL RIGHTS, CLAIMS AND CAUSES OF ACTION I HAVE OR MAY HAVE AGAINST THE MILL GYM OR ANYONE ASSOCIATED WITH THE MILL GYM PTY LTD AND ITS ASSOCIATES, ITS AGENTS, EMPLOYEES, OFFICERS, DIRECTORS, SUCCESSORS AND ASSIGNS THAT MAY ARISE AS A RESULT OF MY PARTICIPATION IN THE MILL GYM CLASSES OR EVENTS AND ANY PRE AND POST CLASS EVENTS ACTIVITIES. I ACKNOWLEDGE THAT IN PROVIDING THIS RELEASE I AM NOT RELYING ON ANY REPRESENTATIONS MADE BY OR ON BEHALF OF THE MILL GYM AND DO SO OF MY OWN FREE WILL. FURTHER, I GRANT FULL PERMISSION TO THE MILL GYM TO USE ANY PHOTOGRAPHS, MOTION PICTURES, RECORDINGS, OR ANY OTHER RECORD OF THESE CLASSES OR EVENTS FOR ANY LEGITIMATE PURPOSE INCLUDING COMMERCIAL ADVERTISING. IF I AM SIGNING ON BEHALF OF A MINOR CHILD, I ALSO GIVE FULL PERMISSION FOR ANY PERSON CONNECTED WITH THE MILL GYM TO ADMINISTER FIRST AID DEEMED NECESSARY, AND IN CASE OF SERIOUS ILLNESS OR INJURY, I GIVE PERMISSION TO CALL FOR MEDICAL AND OR SURGICAL CARE FOR THE CHILD AND TO TRANSPORT THE CHILD TO A MEDICAL FACILITY DEEMED NECESSARY FOR THE WELL-BEING OF THE CHILD. INDEMNIFICATION: I RECOGNISE THAT THERE IS RISK INVOLVED IN THE TYPES OF ACTIVITIES OFFERED AT THE MILL GYM. I ACCEPT LIABILITY FOR ANY INJURY THAT I MAY CAUSE EITHER TO ME OR TO ANY OTHER PARTICIPANT DUE TO MY NEGLIGENCE, OR MY INTENTIONAL ACTS OR OMISSIONS. I AGREE TO INDEMNIFY AND HOLD HARMLESS THE MILL GYM PTY LTD, ITS PRINCIPALS, DIRECTORS, AGENTS, EMPLOYEES, AND VOLUNTEERS FROM LIABILITY FOR THE INJURY OR DEATH OF ANY PERSON(S) AND DAMAGE TO PROPERTY THAT MAY RESULT FROM MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION WHILE TRAINING AT THE MILL GYM OR WHILST ENGAGING IN ACTIVITIES OFFERED BY THE MILL GYM PTY LTD. I HAVE READ AND UNDERSTOOD THE FOREGOING ACKNOWLEDGMENT OF RISK, RELEASE OF LIABILITY AND INDEMNITY PRIOR TO SIGNING IT AND THAT IT SHALL BE BINDING UPON MY HEIRS AND ASSIGNS. BY CLICKING ON 'I AGREE' BELOW, I HAVE READ AND UNDERSTOOD THE FOREGOING WAIVER, RELEASE AND INDEMNITY AND I UNDERSTAND THAT BY CHECKING THIS BOX, IT OBLIGES ME TO INDEMNIFY THE PARTIES NAMED IN RESPECT OF LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION. I UNDERSTAND THAT BY CHECKING THIS BOX I AM WAIVING VALUABLE LEGAL RIGHTS. -- THE MILL GYM MAY USE PHOTOGRAPHS TAKEN DURING THIS PROGRAM IN PROMOTIONAL AND ADVERTISING MATERIAL. THESE PHOTOGRAPHS WILL NOT BE ON SOLD TO ANY THIRD PARTY AND WILL ONLY BE USED IN THE PROMOTION AND ADVERTISING OF CADRE CAMP PROGRAMS AND INITIATIVES. PLEASE LET THE MILL GYM KNOW IF YOU DO NOT WANT YOUR IMAGES USED. THE MILL GYM MAY ALSO USE YOUR EMAIL ADDRESS TO NOTIFY YOU OF UPCOMING ADVENTURES/PROMOTIONS. YOUR INFORMATION WILL NOT BE GIVEN TO A THIRD PARTY AT ANY TIME. PLEASE LET THE MILL GYM KNOW IF YOU DO NOT WISH TO RECEIVE PROMOTIONAL EMAILS. I ACKNOWLEDGE THAT THE ENJOYMENT AND EXCITEMENT OF ADVENTURE PROGRAMS ARE DERIVED IN PART FROM RISKS INCURRED BY PARTICIPATION IN THOSE ACTIVITIES, AND THAT THESE RISKS MAY EXCEED THOSE COMMONLY ACCEPTED AT WORK OR AT HOME. I ACCEPT ALL THE ABOVEMENTIONED RISKS OF MY PROGRAM, AND THE POSSIBILITY OF PERSONAL INJURY, LOSS OR PROPERTY DAMAGE RESULTING THEREFROM, AND WILL HOLD THE MILL GYM ITS EMPLOYEES AND AGENTS FREE FROM ANY AND ALL LIABILITY, ACTIONS, DEBTS, CLAIMS AND DEMANDS OF ANY NATURE WHATSOEVER, SUBJECT TO THE RIGHTS AND PRIVILEGES WHICH APPLY UNDER THE FAIR TRADING ACT (1984), THE COMPETITION AND CONSUMER ACT (2010), & THE CIVIL LIABILITY AMENDMENT ACT 2003. IN ENTERING THIS AGREEMENT I AM NOT RELYING ON ANY REPRESENTATIONS MADE BY OR ON BEHALF OF THE MILL GYM BUT DO SO ONLY OF MY OWN FREE WILL. FIRST AID CONSENT: IN THE EVENT I SUFFER INJURY OR ILLNESS, THE MILL GYM HAS MY CONSENT TO ADMINISTER FIRST AID AND MAY ARRANGE SUCH MEDICAL TREATMENT AND EMERGENCY EVACUATION AS IT CONSIDERS NECESSARY FOR MY SAFETY. I CONFIRM THAT I HAVE READ AND UNDERSTOOD THIS AGREEMENT PRIOR TO SIGNING IT, AND IT SHALL BE BINDING UPON MY HEIRS, EXECUTORS, ASSIGNS AND NEXT OF KIN. I AGREE Thank you!
