Signup

All clients or guests must complete this form prior to using the facility. All information collected remains confidential. 

• Full name: {name} 

• Date of birth: {dob} 
• Gender: {Gender}
• Phone number: {phone}
• Member address: {address} 
• Emergency contact:  {contact_name}  
• Emergency contact phone#: {contact_phone} 
• Emergency contact relation: {contact_relation} 

I hereby release SAMSON HEALTH CLUB of any accident, injury, disability, or death which may be caused by or result from my participation while engaging in activities at or sponsored by any of the staff members except where damage or injury is caused by the negligence of SAMSON HEALTH CLUB staff and employees within the scope of their duties. I further agree that I, the undersigned, have no knowledge of any physical illness or disability that through my participation could prove dangerous or hazardous to my health. 

In the event where I elect to participate in a Cold Plunge or Sauna session at Samson Health Club. I agree to observe and obey all posted rules and warnings and further agree to follow any oral instructions or directions given by a gym representative. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest Samson Representative immediately.

I recognize that severe injuries, including permanent paralysis or death can occur in sports or activities including but not limited to breath work, training routines with ice/cold/heat, extreme cold, ice baths, weather conditions, condition of participants, equipment, or other factors.  

While particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury still does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of Plunge or others such as volunteers and trainers, and I assume full responsibility for my participation.

PHOTOGRAPH LICENSE

I understand while participating in this activity, I may be filmed or photographed. I grant a license to the activity organizer and affiliates to use my photo, video, or film likeness to be used for any legitimate purpose.

Date document was signed {sign_date}