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Liability Waiver and Health History Form

I have agreed to participate in an exercise program. I waive any and all possibilities of personal damage which may result from participation in this exercise program now and in the future, and I accept full responsibility for requesting such an exercise program.

The possibility of certain changes does exist during exercise and fitness evaluations. Some of the changes include: abnormal breathing, abnormal blood pressure, fainting, irregular heart beats, and a very rare instance of heart attack.

Every effort will be made to minimize problems that may arise. I hereby acknowledge these risks. To my knowledge, I do not have any limiting factors, physical conditions or disabilities which would preclude an exercise program or fitness evaluation.

I have been informed that a Physician’s approval has been suggested and recommended prior to participating in the exercise program or fitness evaluation. I understand the strenuous nature of this program and or fitness evaluation process.

I accept full responsibility for my health and well being in the voluntary exercise and fitness program. I fully understand that no responsibility is assumed by the Personal Trainer, Administrators, the Facility, and the Owners.

I give my permission for Explosion Fitness Solutions to display my picture on their advertising materials such as, the website, brochure, marketing fliers.

 

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additional Information:
Location that you will be training at: *
Fairfield
Mason
Association Specifics

Please enter NA if the question does not apply


Club/Team *

School *

Sport *
Health Questionnaire:

What is your current level of activity? (Work and leisure pursuits)
Are you currently participating in a regular exercise program?*
No
Yes

If YES, please explain:

Are you taking any medication, drugs, vitamins, herbs, or other supplements? If so, please list type, dose, and reason.
Are you seeing a specialist or therapist?*
No
Yes

If yes, Please provide phone number, and office location.

Physician's Name, Phone Number, and Office Location.
Does your physician or specialist know you are participating in this program?*
No
Yes
Do you now or have you had in the past:
History of heart problems in family? (mother, father, sibling, grandparent)How old were they?*
No
Yes

If YES, please explain:
Cigarette smoking or other tobacco habit?*
No
Yes
Elevated blood pressure or taking blood pressure medication?*
No
Yes

If YES, please explain:
High cholesterol, triglycerides, or on lipid lowering medications?*
No
Yes

If YES, please explain:

What is your Total Cholesterol Level?
Diabetes or thyroid condition, impaired fasting glucose?*
No
Yes

If YES, please explain:
Any chronic illness or condition?*
No
Yes

If yes, please explain:
Difficulty with physical exercise?*
No
Yes

If YES, please explain:
Advice from medical professional not to exercise?*
No
Yes

If YES, please explain:

Recent surgery? (last 12 months) Please List:
Pregnancy (now or within last 3 months)?*
No
Yes
History of allergy, breathing or lung problems?*
No
Yes

If YES, please explain:

Muscle, joint, or back disorder, or nay previous injury still affecting you? Please Explain:
A heart condition or heart vascular disease?*
No
Yes

If YES, please explain:
Do you have pain, discomfort, or other anginal equivalent in the chest,Neck, jaw, arms, or other areas that may be due to lack of blood flow?*
No
Yes

If YES, please explain:
Dizziness or fainting?*
No
Yes

If YES, please explain:
Troubled or rapid breathing at night or the need to sit up to breath?*
No
Yes

If YES, please explain:
Ankle or leg swelling?*
No
Yes
Rapid heat beating or palpitations?*
No
Yes

If YES, please explain:
A known heart murmur?*
No
Yes
Unusual fatigue or shortness of breath with usual activities?*
No
Yes

If YES, please explain:
Weight & Goals:

Current Weight:

What do you feel is your ideal weight?

What are your personal fitness goals? What do you hope to accomplish through personal training?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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