Counter Punch LLC

Membership Application & Liability Waiver

Facility Name: Counter Punch LLC

Facility Type: Fitness & Boxing Training Center

Address
9340 White Oak Crossing, Suite C
North Little Rock, AR 72113

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Date of Application

Section 1 – Member Information

Full Name*

Date of birth

Age

Gender (Optional)

Male

Female

Other

Prefer not to say

Home Address

Street Address City State ZIP Code

Mobile Phone*

Email Address*

Preferred contact method

Call

Text

Emergency contact name

Relationship

Emergency contact phone

Section 2 – Membership Details

Membership Type (Select One)

Drop-In / Single Session

Monthly Membership

3-Month Membership

6-Month Membership

Annual Membership

Other

Start Date

Preferred training times

Morning

Midday

Evening

Flexible

Primary training interests

Boxing Fitness

Strength & Conditioning

Cardio / Weight Loss

Youth Training

Personal Training

Other

Section 3 – Health & medical information

The following questions help us understand your current health status. They do not replace medical advice. Always consult your physician before starting any exercise program.

1. Do you have any current or past medical conditions (e.g., heart disease, high blood pressure, asthma, diabetes, joint problems)?

Yes

If yes, please describe

2. Have you ever been advised by a doctor to avoid or limit physical activity?

Yes

If yes, please explain

3. Are you currently taking any medications that may affect your ability to exercise?

Yes

If yes, please list

4. Do you have any injuries, physical limitations, or conditions we should be aware of (e.g., back, knee, shoulder, neck)?

Yes

If yes, please describe

5. Do you have any allergies (including to latex, medications, or environmental factors)?

Yes

If yes, please list

6. Are you pregnant or postpartum?

Yes

N/A

Physician’s Name

Physician’s Phone

Section 4 – Participant Acknowledgements

Initial each statement:

Untitled

I understand that boxing, fitness training, and related activities involve physical exertion and may be strenuous.

Untitled

I understand it is my responsibility to consult with a physician prior to beginning any exercise program.

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I agree to immediately inform staff if I experience pain, dizziness, shortness of breath, or any unusual discomfort during training.

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I understand that failure to follow instructions, use equipment properly, or disclose relevant health information may increase my risk of injury.

Section 5 – Liability waiver & assumption of risk

In consideration of being allowed to use the facilities, equipment, programs, and services of Counter Punch LLC (the “Gym”), I, the undersigned, agree as follows:

1. Assumption of risk

I understand and acknowledge that participation in boxing, fitness training, conditioning, and related activities involves inherent risks, including but not limited to: falls, collisions, contact with other participants, use or misuse of equipment, overexertion, muscle strains, sprains, fractures, cardiovascular events, and other injuries or health complications.

I voluntarily choose to participate in these activities and **freely assume all risks**, known and unknown, including those that may arise from the negligence of the Gym, its owners, officers, employees, trainers, contractors, and agents (collectively, the “Released Parties”), to the fullest extent permitted by law.

2. Release of liability

To the fullest extent permitted by applicable law, I hereby **release, waive, discharge, and hold harmless** the Released Parties from any and all claims, demands, causes of action, damages, losses, costs, or liabilities of any kind, whether known or unknown, arising out of or related to my participation in any activities at or sponsored by Counter Punch LLC, including but not limited to personal injury, illness, property damage, or wrongful death, even if caused in whole or in part by the negligence of the Released Parties.

3. Indemnification

I agree to **indemnify and defend** the Released Parties against any and all claims, demands, actions, or suits brought by or on behalf of me, my family, estate, heirs, or assigns, or by any third party arising out of my actions, conduct, or participation in activities at the Gym.

4. Medical Authorization

In the event of an injury or medical emergency, I authorize the Gym and its staff to obtain or provide emergency medical care as they deem necessary, including transportation by ambulance. I understand that I am solely responsible for any and all medical costs incurred as a result of such care.

5. Physical condition & disclosure

I represent that I am in sufficient physical condition to safely participate in the activities offered by the Gym and that I have disclosed all relevant medical conditions, injuries, and limitations. I understand that the Gym does not provide medical advice and that I should consult my own healthcare provider regarding my ability to participate.

6. Rules, conduct, & facility use

I agree to comply with all Gym rules, policies, and instructions, including but not limited to safety rules, equipment use guidelines, and staff directions. I understand that the Gym may revoke my access or membership, without refund, for unsafe, disruptive, or inappropriate behavior.

7. Personal Property

I understand that I am solely responsible for my personal belongings and property. The Gym is not responsible for loss, theft, or damage to any personal items brought onto the premises.

8. Photo & media release (Optional)

I Do

I Do Not

Consent to Counter Punch LLC photographing, recording, or otherwise capturing my image, likeness, or voice during activities, and using such media for promotional, marketing, or educational purposes in print, online, or social media, without compensation. I understand that I may revoke this consent in writing prospectively, but not as to materials already produced.

9. Minor Participants (If Applicable)

If the participant is under 18 years of age, this section must be completed by a parent or legal guardian.

Minor’s Name

Date of birth

I am the parent or legal guardian of the above-named minor. I have read and understood this Membership Application & Liability Waiver. I consent to the minor’s participation in all activities at Counter Punch LLC and agree to all terms on the minor’s behalf, including the assumption of risk, release of liability, and indemnification provisions.

Parent/Guardian Name

Signature

By typing your name, you are signing this form.

Date

Section 6 – Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of Arkansas, without regard to its conflict of law principles. If any provision is found invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Section 7 – Acknowledgement & signature

By signing below, I acknowledge that I have **carefully read this Membership Application & Liability Waiver**, understand its terms, and agree that I am giving up substantial legal rights, including the right to sue. I sign this document freely and voluntarily, intending it to be a complete and unconditional release of liability to the fullest extent permitted by law.

Member/Participant Name

Signature

By typing your name, you are signing this form.

Date

If signed electronically*

I agree that my electronic signature has the same legal effect as a handwritten signature.

Counter Punch LLC Representative

Name

Title

Signature

By typing your name, you are signing this form.

Date

Membership Application & Liability Waiver

Address

Phone

Email

Website

Section 1 – Member Information

Section 2 – Membership Details

Section 3 – Health & medical information

Section 4 – Participant Acknowledgements

Section 5 – Liability waiver & assumption of risk

Section 6 – Governing Law

Section 7 – Acknowledgement & signature

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