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Acknowledgment of Participation 

All Bloom athletes must have a completed acknowledgment on file before participating in Bloom activities. Answers are confidential and only shared with pertinent Bloom staff/volunteers.
1.Who is completing this survey?(Required.)
2.What is the athlete's name?(Required.)
3.Please provide an email address that is unique to the athlete. This can be a parent/guardian/family member email address. Unique addresses are REQUIRED to set up their Bloom app experience.(Required.)
4.Secondary email (if available).
5.What is the athlete's age?(Required.)
6.Where does your athlete attend class? (Selectyour partner affiliation or "virtual" for at-home services only.)(Required.)
7.What is the athlete's shirt size?(Required.)
8.What is the athlete's shorts size?(Required.)
9.Please rate the following statements based on the athlete's current physical fitness level:(Required.)
Never
Rarely
Sometimes
Regularly
Almost Every Day
Participates in physical fitness 
Requests to participate in physical fitness 
Talks about the benefits of physical fitness 
10.Please rate the following statements based on the athlete's current sense of belonging:(Required.)
Never
Rarely
Sometimes
Regularly
Almost Every Day
Feels he/she is an important member of a group 
Feels like a contributing member of a fitness program 
Has a sense of belonging outside of the family unit 
11.Please rate the following statements based on the athlete's current mental health.(Required.)
Very Poor
Poor
Neutral/No Opinion
Good
Very Good
Interest in Wellness
Self-esteem 
Sense of belonging to a community 
Ability to self-advocate for one's own wellness 
12.How would you rate the athlete in the following areas?(Required.)
Very Poor
Poor
Fair
Good
Excellent
Overall health 
Self-esteem 
Group social skills 
Independent fitness/wellness decision skills 
13.WAIVER AND GENERAL RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK
You recognize and acknowledge that there are inherent risks of physical injury to Bloom Athlete in any fitness activities, including Bloom Programs, and you voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that you may sustain as a result of said participation. As a material inducement for Bloom to permit you to participate in Bloom Programs, you hereby, on behalf of yourself, your heirs, executors and assigns, fully, forever and irrevocably waive, release and hold Bloom, its, directors, agents, representatives, employees, consultants, affiliated entities, partners, and successors (collectively “Bloom Parties”) harmless from any and all claims (including, to the extent permitted by applicable law, claims alleging negligence on behalf of any Bloom Party), injuries, damages or loss (including legal fees), present or future, foreseen or unforeseen, anticipated or unanticipated (collectively “Claims”), that you may have (or that accrue to you) against any Bloom Party, and generally release and discharge the Bloom Parties from any and all Claims, including but not limited to those involving: (i) participating in any supervised or unsupervised fitness activities, (ii) use of any fitness equipment, (iii) any loss or theft of personal property, and (iv) accidental injuries, such as “slip and fall” injuries on or outside of Bloom premises, and you hereby promise never to assert or assist any other party in asserting, any claims or causes of action against any Bloom Party in any matter that in any way relates to any Claims. 

By typing my name below, I represent that I fully understand the above and have the authority to represent the athlete listed in question 2 above. (Required.)
Current Progress,
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