Welcome to Brandywine CrossFit (keep this page)
Welcome! This packet contains useful information to us, and you.
Please read through it, fill out and return all except the first two pages.
Those you may hold on to future reference. On the day of your first
intro class, please bring:
 Completed remainder of this packet
 Your payment information
 Dressed to train
 Water
 Towel (if desired)
Membership at BWCF
Each workout of the day (WOD) is a 1-hour class performed in a group
setting. Experienced CrossFitters are welcome to join directly into our
regular classes. All new CrossFitters must complete our Intro Course
before joining a regular class. See Get Started page for more
information under the BWCF Info tab on our website (www.bwcf.net).
Once you have either completed the Intro Course or are already an
experienced CrossFitter, we offer the following memberships:
Unlimited Monthly - $140
Student/Military/First Responder Unlimited Monthly - $100
For our members who travel or cannot make it to the gym regularly
we also offer a 10-class punch card for $150. These cards do not
expire.
CrossFitters passing through the area are welcome to drop in for a
workout – $20
Classes at BWCF
Each class session lasts one hour and starts with a guided warm-up.
Before the workout, coaches will instruct athletes on the finer points of
the movements and allow for technique refinement and practice. Once
the workout begins, our coaches guide the group to the highest level
of intensity possible, relative to each athlete.
Box Rules (keep this page)
Show up on time. Our group led warm up is an integral part
of our classes and missing them may result in injury. Be
respectful and on time.
Listen to your coaches; they are here to help you. Any cues
they provide you are for your own benefit and may be
something very valuable.
Introduce yourself to new members. It’s nice to know whom
you are sweating with.
Set up your equipment.
Learn to count …don’t cheat. (You may not know it but your
coaches and fellow members may be counting your reps.)
Do each rep with good form and full range of motion; no
matter the time it takes you. Train with integrity.
Clean up your equipment, once everyone from your heat is
finished. It’s the respectful way.
Clean up your DNA.
Cheer on your fellow CrossFitters. We are here as a
community to help and support one another. If we didn’t
like the CrossFit way, we’d be in a private gym, grunting
alone. Show your support.
Respect the equipment. Do not drop your empty barbells; it
can ruin the internal bearings.
Break your last PR.
Have fun, laugh, and smile a lot. We joke, yell, swear and
grunt.
Be patient. Train, do not “workout.”
Release of Liability
1. In consideration of being allowed to participate in a fitness assessment and personal
fitness program provided by _Kelly Megill, Wayne Megill, Victoria Dosen, Adriane
Wiltraut, Mike Costill, Helen Serth_, (or any other employee of Brandywine CrossFit
“Trainer”) and to use his facilities (Brandywine CrossFit @ 276 Dilworthtown Rd, West
Chester), equipment and services, in addition to the payment of any fee or charge, I do
hereby forever waive, release and discharge Trainer and his agents, employees,
representatives, executors and all others acting on his behalf from any and all claims or
liabilities for injuries or damages to my person and/or property, including those caused
by the negligent act or omission of any of those mentioned or others acting on his
behalf, arising out of or connected with my participation in any activities, programs or
services of Trainer or the use of any equipment provided and/or recommended by
Trainer. (Initials: _______)
2. 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, including a remote risk of death or
serious disability, 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.
(Initials: _______)
3. I do hereby further declare myself to be over the age of eighteen as of the date of
signing this document, physically sound and suffering from no condition, impairment,
disease, infirmity or other illness that would prevent my participation in these activities,
whether or not the activities require the use of any equipment. I do hereby
acknowledge that I have been informed of the need for a physician's approval for my
participation in the fitness program. I acknowledge that either I have had a physical
examination and have been given my physician's permission to participate or I have
decided to participate in the exercise activities, programs and use of equipment without
the approval of my physician and do hereby assume all responsibility for my
participation in said activities, programs and use of equipment.
(Initials: _______)
4. I understand that all information and services provided by Trainer is of a general
nature and is provided for educational purposes only. None of the information or
services provided by Trainer is to be taken as medical or other health advice pertaining
to any specific health or medical condition that I may have or have had. The
information and services provided by Trainer is not a diagnosis, treatment plan, or
recommendation for a particular course of action regarding my health and is not
intended to provide specific medical advice.
(Initials: _______)
Signature ___________________________ Print Name _______________________
Address _____________________________________________________________
Today’s Date ________________ Email ____________________________________
Health and Medical History (PLEASE PRINT LEGIBLY)
Name ___________________________________________
Date ________________________
Email ___________________________________________
Street address ____________________________________
City/State/Zip ___________________________________________________
Phone (home) ______________________________
(cell) _____________________________
Date of Birth __________/__________/___________
How did you hear about us?
Internet
Drive By
Friend /Member
Advertisement
Word of Mouth
Other:_____________________________________
Emergency contact:
Name / Relationship _____________________________
Phone ________________________
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.
Yes
___
No
___
1. Are you over age 55 and/or not accustomed to vigorous exercise?
___
___
2. Have you ever been diagnosed with Type I or Type II Diabetes?
___
___
3. Do you have any reason to suspect that you might now pregnant, or have you
been pregnant within the last 3 months?
___
___
4. Have you had any major or minor surgery in the past 3 months?
___
___
5. Have you been hospitalized in the last 2 years? If so, when and for what reason?
___________________________________________________________________
___
___
6. Are you currently, or have you in the past, ever seen a chiropractor or physical
therapist for any condition? If yes, when and for what condition?
___________________________________________________________________
___
___
7. Do you ever experience unexpected shortness of breath, or labored breathing,
with or without pain? If yes, describe under what conditions.
_________________________________________________________________________
___
___
___
___
8. Do you currently, or have you ever, experienced unexplained heart palpitations or
been diagnosed with a heart murmur or irregular heartbeat?
9. Have you ever been diagnosed with high blood pressure?
when?__________
If yes,
___
___ 10. Do you know what your blood pressure normally is? If yes, please state _______
/ _______
___
___ 11. Do you currently smoke? If yes, how many cigarettes per day?_______
___
___ 12. Did you ever smoke? If yes, how long ago did you quit?
___
___ 13. Is there any history of heart disease (prior to age 55) in your immediate family? If
yes, explain.
___________________________________________________________________________
___
___ 14. Do you know your cholesterol
____________________________
___
___
levels?
If
so,
please
state:
15. Do you receive regular annual physical exams from your primary care physician?
Date of last exam:
___________________________
___
___ 16. Do you have any pain, discomfort, or known current or previous injury to any of
the following areas:
___
___
Right or left knee (circle as appropriate)
___
___
Right or left shoulder (circle as appropriate)
___
___
Right or left elbow (circle as appropriate)
___
___
Right or left elbow (circle as appropriate)
___
___
Right or left wrist (circle as appropriate)
___
___
Right or left ankle (circle as appropriate)
___
___
Right or left hip (circle as appropriate)
___
___
Back or neck (circle as appropriate)
If you checked “Yes” to any of the above, please explain the nature of your pain
and/or injury. Do certain activities or conditions aggravate the pain and/or injury?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Are there any other health/medical/injury conditions that your trainer should be aware of?
__________________________________________________________________________________
Please list any prescription medications or over-the-counter medications or supplements you
currently take:
_________________________________________________________________________________
I, ________________________________________, certify that I understand the foregoing questions
and my answers are true and complete. I also understand that if this information changes in any way
in the future, it is my responsibility to notify my personal trainer, and that I assume the risk for any
changes in my medical condition that might affect my ability to exercise.
Before beginning a new fitness program or other significant change in your physical activity levels,
you are advised to consult with your physician or primary health care provider. Only a physician or
qualified health care provider is able to diagnose and prescribe treatment for specific health
conditions.
I acknowledge that I have read the foregoing statements and fully understand the content thereof, and
that if I choose not to consult with my physician or primary health care provider, I do so at my own
risk.
_________________________________________________________
Signature
Date
_________________________________________________________
Please print name
_________________________________________________________
Parent or legal guardian (if participant is under age eighteen) Date
Payment Profile
We accept MasterCard and Visa, Cash or Check. Our memberships are
on a month-to-month basis; we don’t do “contracts.” In order to
streamline our billing system, we ask that you provide us with either a
credit card information so we may put it in your personal payment
profile. We will charge your account on or about the first of each month,
unless you provide us with an email or written request prior to the next
month’s billing (i.e. two week’s notice) for a change in membership.
___ Credit Card (Visa or MasterCard)
Credit Card # ________-________-________-________
Expiration Date _________/________
Billing Information, if different from given address or athlete:
Name _______________________________
Address _____________________________________
____________________________________________
Package Purchased
Unlimited membership at $140 will be billed going forward. The
second month will be prorated, if necessary, based on the initial date.
Or please check below if you are purchasing:
______ Mil/Stud/1st Responder ($100)
______ Class Card – 10 classes ($150)
By signing, I allow Brandywine CrossFit to charge my credit card
(recommended) and I understand that 2 weeks notice, in writing, is
required for membership change or cancellation.
INTROS NEEDED
____YES
_____NO
______________________
STAFF MEMBER APPROVING
(INTRO MONTH $170)
Member Signature ________________________________________
Today’s Date __________________________