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Sarah Vande Berg Tennis and Wellness Center

We are honored that you have chosen SVB to assist you in incorporating fitness and racket sports into your lifestyle.

If there is anything we can do to make you more comfortable, please let us know.

Today's Date: January 20, 2022

First Participant's Name

First Name*

Last Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
First Participant's Signature*
Second Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
Third Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
Fourth Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
Fifth Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
Sixth Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
Seventh Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
Eighth Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
Ninth Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
Tenth Participant's Name

First Name*

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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
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*
How did you hear about SVB

How did you hear about SVB

If Referred by someone, who?

May we contact any potential referrals you would like to recommend?
Social Media Consent
I hereby give my full consent to Sarah Vande Berg Tennis & Wellness Center to use my unsolicited testimonial and/ or photograph of me or my child, to whom I am the legal parent or guardian. I understand my testimonial and photography which I have freely provided will be used for promotional, technical or informational purposes as deemed in knowing the results I have obtained. I understand that this consent will not expire unless I provide written notice indicating my wishes to discontinue it's use.
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

Current Injuries

Medical History/Medications

Current Physical Activities
Do you smoke?*
No
Yes
Do you have any allergies?*
No
Yes
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes

What are your goals
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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