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.

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* 1. Who is completing this survey?

An athlete

An athlete's parent/guardian

A partner agency employee

Other (please specify)

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* 2. What is the athlete's name?

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* 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.

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* 4. Secondary email (if available).

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* 5. What is the athlete's age?

Under 20 years old

20-29 years old

30-39 years old

40-49 years old

50-59 years old

Over 60 years old

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* 6. Where does your athlete attend class? (Selectyour partner affiliation or "virtual" for at-home services only.)

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* 7. What is the athlete's shirt size?

2XL

3XL

4XL

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* 8. What is the athlete's shorts size?

2XL

3XL

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* 9. Please rate the following statements based on the athlete's current physical fitness level:

	Never	Rarely	Sometimes	Regularly	Almost Every Day
Participates in physical fitness	Participates in physical fitness Never	Participates in physical fitness Rarely	Participates in physical fitness Sometimes	Participates in physical fitness Regularly	Participates in physical fitness Almost Every Day
Requests to participate in physical fitness	Requests to participate in physical fitness Never	Requests to participate in physical fitness Rarely	Requests to participate in physical fitness Sometimes	Requests to participate in physical fitness Regularly	Requests to participate in physical fitness Almost Every Day
Talks about the benefits of physical fitness	Talks about the benefits of physical fitness Never	Talks about the benefits of physical fitness Rarely	Talks about the benefits of physical fitness Sometimes	Talks about the benefits of physical fitness Regularly	Talks about the benefits of physical fitness Almost Every Day

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* 10. Please rate the following statements based on the athlete's current sense of belonging:

	Never	Rarely	Sometimes	Regularly	Almost Every Day
Feels he/she is an important member of a group	Feels he/she is an important member of a group Never	Feels he/she is an important member of a group Rarely	Feels he/she is an important member of a group Sometimes	Feels he/she is an important member of a group Regularly	Feels he/she is an important member of a group Almost Every Day
Feels like a contributing member of a fitness program	Feels like a contributing member of a fitness program Never	Feels like a contributing member of a fitness program Rarely	Feels like a contributing member of a fitness program Sometimes	Feels like a contributing member of a fitness program Regularly	Feels like a contributing member of a fitness program Almost Every Day
Has a sense of belonging outside of the family unit	Has a sense of belonging outside of the family unit Never	Has a sense of belonging outside of the family unit Rarely	Has a sense of belonging outside of the family unit Sometimes	Has a sense of belonging outside of the family unit Regularly	Has a sense of belonging outside of the family unit Almost Every Day

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* 11. Please rate the following statements based on the athlete's current mental health.

	Very Poor	Poor	Neutral/No Opinion	Good	Very Good
Interest in Wellness	Interest in Wellness Very Poor	Interest in Wellness Poor	Interest in Wellness Neutral/No Opinion	Interest in Wellness Good	Interest in Wellness Very Good
Self-esteem	Self-esteem Very Poor	Self-esteem Poor	Self-esteem Neutral/No Opinion	Self-esteem Good	Self-esteem Very Good
Sense of belonging to a community	Sense of belonging to a community Very Poor	Sense of belonging to a community Poor	Sense of belonging to a community Neutral/No Opinion	Sense of belonging to a community Good	Sense of belonging to a community Very Good
Ability to self-advocate for one's own wellness	Ability to self-advocate for one's own wellness Very Poor	Ability to self-advocate for one's own wellness Poor	Ability to self-advocate for one's own wellness Neutral/No Opinion	Ability to self-advocate for one's own wellness Good	Ability to self-advocate for one's own wellness Very Good

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* 12. How would you rate the athlete in the following areas?

	Very Poor	Poor	Fair	Good	Excellent
Overall health	Overall health Very Poor	Overall health Poor	Overall health Fair	Overall health Good	Overall health Excellent
Self-esteem	Self-esteem Very Poor	Self-esteem Poor	Self-esteem Fair	Self-esteem Good	Self-esteem Excellent
Group social skills	Group social skills Very Poor	Group social skills Poor	Group social skills Fair	Group social skills Good	Group social skills Excellent
Independent fitness/wellness decision skills	Independent fitness/wellness decision skills Very Poor	Independent fitness/wellness decision skills Poor	Independent fitness/wellness decision skills Fair	Independent fitness/wellness decision skills Good	Independent fitness/wellness decision skills Excellent

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* 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.