Loading...

ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT

DECLARATIONS: This Agreement is entered into between personal trainer (“Trainer”) and the undersigned (“Client”). The provision of personal training services by Trainer to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

ASSUMPTION OF RISK: You agree that if you engage in any physical exercise or activity, including personal training, or enter our premises or use any facility or equipment on our premises for any purpose, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Trainer or otherwise, including injuries or damages arising out of the negligence of Trainer, whether active or passive, or any of Trainer’s affiliates, employees, agents, representatives, successors, and assigns.

Your assumption of risk includes, but is not limited to, your use of any exercise equipment (mechanical or otherwise), sports fields, courts, or other areas, locker rooms, sidewalks, parking lots, stairs, pools, whirlpools, saunas, steam rooms, lobby or other general areas of any facilities, or any equipment.

You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to weightlifting, walking, jogging, running, aerobic activities, aquatic activities, tennis, basketball, volleyball, racquetball, or any other sporting or recreational endeavor.

You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Trainer or otherwise. 

I Agree

RELEASE: You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Trainer (and Trainer’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Trainer, whether active or passive, or any of Trainer’s affiliates, employees, agents, representatives, successors, and assigns.

This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including personal training, (d) negligent hiring or retention of employees, and/or (e) slipping or tripping and falling while on any portion of a premises or while traveling to or from personal training, including injuries resulting from Trainer’s or anyone else’s negligent inspection or maintenance of the facility or premises. 

I Agree

INDEMNIFICATION: By execution of this agreement, you hereby agree to indemnify and hold harmless Trainer from any loss, liability, damage, or cost Trainer may incur due to the provision of personal training by Trainer to you.

I Agree

ACKNOWLEDGMENTS: You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law in the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

You acknowledge that Trainer offers a service to his/her clients encompassing the entire recreational and/or fitness spectrum. Trainer is not in the business of selling weightlifting equipment, exercise equipment, or other such products to the public, and the use of such items is incidental to the service provided by Trainer.

You acknowledge and agree that Trainer does not place such items into the stream of commerce. This release is not intended as an attempted release of claims of gross negligence or intentional acts. You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement.

You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against trainer for trainer’s negligence, or for any defective product used while receiving personal training from trainer. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made. 

I Agree

Date Signed: September 20, 2019

First Athlete's Name

First Name*

Last Name*

Phone*
First Athlete's Date of Birth*
First Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
First Athlete's Signature*
Second Athlete's Name

First Name*

Last Name*
Second Athlete's Date of Birth*
Second Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Third Athlete's Name

First Name*

Last Name*
Third Athlete's Date of Birth*
Third Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Fourth Athlete's Name

First Name*

Last Name*
Fourth Athlete's Date of Birth*
Fourth Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Fifth Athlete's Name

First Name*

Last Name*
Fifth Athlete's Date of Birth*
Fifth Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Sixth Athlete's Name

First Name*

Last Name*
Sixth Athlete's Date of Birth*
Sixth Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Seventh Athlete's Name

First Name*

Last Name*
Seventh Athlete's Date of Birth*
Seventh Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Eighth Athlete's Name

First Name*

Last Name*
Eighth Athlete's Date of Birth*
Eighth Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Ninth Athlete's Name

First Name*

Last Name*
Ninth Athlete's Date of Birth*
Ninth Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Tenth Athlete's Name

First Name*

Last Name*
Tenth Athlete's Date of Birth*
Tenth Athlete's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
Parent or Guardian's Email Address

Email*

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

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Medical History

Are you currently under a doctor's care:*
No
Yes

If yes, explain:

When was the last time you had a physical examination?
Do you take any medications on a regular basis?*
No
Yes

If yes, please list medications and reasons for taking:
Have you been recently hospitalized?*
No
Yes

If yes, explain:
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Do you drink alcohol more than three times/week?*
No
Yes
Is your stress level high?*
No
Yes
Are you moderately active on most days of the week?*
No
Yes

Have parents or siblings who, prior to age 55 had:

A stroke?*
No
Yes
A heart attack?*
No
Yes
High blood pressure?*
No
Yes
High Cholesterol?*
No
Yes

Do you have any of the following?

Diabetes?*
No
Yes
High blood pressure?*
No
Yes
High cholesterol?*
No
Yes
Known heart disease?*
No
Yes
Rheumatic heart disease?*
No
Yes
A heart murmur?*
No
Yes
Chest pain with exertion?*
No
Yes
Irregular heart beat or palpitations?*
No
Yes
Lightheadedness or do you faint?*
No
Yes
Unusual shortness of breath?*
No
Yes
Cramping pains in legs or feet?*
No
Yes
Emphysema?*
No
Yes
Other metabolic disorders (thyroid, kidney, etc.)?*
No
Yes
Epilepsy?*
No
Yes
Asthma?*
No
Yes
Back pain: upper, middle, lower (explain below)?*
No
Yes
Other joint pain (explain on below)?*
No
Yes
Muscle pain or an injury (explain below)?*
No
Yes

SETTING YOUR HEALTH AND TRAINING GOALS

How can a trainer help you? Please check that which applies.
Get Faster
Get Stronger
Build Endurance
Rehabilitate an Injury
Nutrition Education
Loose Body Fat
Create an Exercise Program
Design a More Advanced Program
Safety
Sports Specific Training
Fun
Motivation

Other

Please list in order of priority, the training goals you would like to achieve in the next 3-12 months?


a.) *

b.) *

c.) *

How will you feel once you've achieved these goals? Be specific *
Where do you rate health in your life?
How committed are you to achieving your training goals?

What do you think the most important thing your Trainer can do to help you achieve your goals? *

Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc. *
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver