Date of birth:
How did you hear about us?
Please state your height:
Please state your weight:
Ever been told by a doctor that you've had a heart attack?
Ever been told by a doctor that you've had a stroke?
Ever been told by a doctor that you have high blood pressure?
Ever been told by a doctor that you have high blood sugar?
Ever been told by a doctor that you have high cholesterol?
Ever experienced unexplained pains in your chest during exercise?
Ever felt faint or dizzy during physical activity or exercise?
Ever had an asthma attack requiring medical attention in the last 12 months?
Ever been diagnosed with a muscle, bone or joint problem that could be worsened by exercise?
Do you have any muscle, bone or joint pain that is worsened by particular types of activity?
Does anyone in yor family have a history of heart disease or stroke?
Are you taking any prescribed medication(s)?
Are you pregnant or have you just given birth within the last 12 months?
Do you have any other medical conditions that may make it dangerous to exercise?
Please add any additional comments if applicable:
Emergency Contact Information
Emergency contact person:
Emergency contact phone:
Emergency contact email:
Their relationship to you:
Terms and Conditions
During your exercise program, every effort will be made to assure your safety. However, physical exercise can be strenuous and subject to risk of serious injury, including increased heart stress and the chance of musculoskeletal injuries. We urge you to obtain a physical examination from a doctor before participating in any exercise activity. You agree that by participating in physical exercise or training activities, you do so entirely at your own risk. You agree that you are voluntarily participating in these activities and assume all risks of injury, illness, or death. We are also not responsible for any loss of your personal property. You acknowledge that you have carefully read this "waiver and release" and fully understand that it is a release of liability . You expressly agree to release and discharge the trainer or instructor from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer or instructor for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from. By signing this release, I acknowledge that I understand its content and that this release cannot be modified orally.