EmailMe Form - Wired Fitness 12 Week Challenge

Name *

First Last

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Mobile Phone *

### - ### - ####

Email *

How did you hear about Wired Fitness? *

Client Referral?

Training Location

Please pick your initial park and time slot for your first class. You can remain in that location or move around between other locations after your initial class.

Please Choose One: *

Any special scheduling notes for your trainer?

Personal | Health Information

Please complete this thoroughly. Even if you do not feel something is significant, your trainer will decide if further explanation is necessary. Thanks in advance for the detail.

Age *

Weight *

Height *

Sex *

MALE

FEMALE

What are your fitness goals? What do you plan on accomplishing here at Wired Fitness? Please be detailed. *

Has your Dr. ever said you have a heart condition? *

YES

NO

Dizziness, loss of balance, or a condition that could lead to unconsciousness? *

YES

NO

Do you have a bone or joint problem aggravated by physical activity? *

YES

NO

High Cholesterol? *

YES

NO

Are you over 65 yrs of age and not accustomed to intense exercise? *

YES

NO

Females, are you pregnant? *

YES

NO

MALE

Are there any other reasons why you shouldn't participate in a physical fitness program)? *

YES

NO

Have you ever had pain or injuries (ankle, knee, hip, back, shoulder, elbow, etc.)? If YES, please explain below. *

YES

NO

Have you ever had any surgeries? If YES, please explain below. *

YES

NO

Are you currently taking any medications? If YES, please explain below. *

YES

NO

Have you ever been diagnosed with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? If YES, please explain below. *

YES

NO

Explain in 'FULL' detail anything that you answered 'YES' to above. If you are taking medications that may be affected by an elevated heart rate, exposure to the sun, blood sugar levels, etc...

Liability Waiver

I, (FULL NAME | DATE BELOW) have read the following waiver, understand, and agree to its contents.

THE FOLLOWING IS A WAIVER. READ IT BEFORE SIGNING. BY AFFIXING MY SIGNATURE TO THIS DOCUMENT, I ATTEST, CONTRACT, UNDERSTAND AND AGREE THAT I AM TO BE LEGALLY BOUND BY ITS CONTENTS. I hereby stipulate and agree: That I realize the risks of cardiovascular exercise, weight lifting, weight training and/or body building, and I am fully aware of the possibility of malfunctions of equipment.

I, therefore fully understand and I am mindful of the serious consequences which might result due to my involvement in cardiovascular exercise, weight lifting, weight training and/or body building while training with Wired Fitness, and based on that understanding, as set forth in this paragraph, I voluntarily assume any and all risk of loss, damage or injury of any kind whatsoever from my use of any and all of the equipment of Wired Fitness, and further and with full knowledge of the consequences (i.e. that I am waiving my right to sue) expressly waive the part of Wired Fitness, and the operator of Wired Fitness, and from my use of Wired Fitness' equipment and/or facilities. That I am physically sound and have medical approval to proceed with a normal routine of exercise. That all exercises shall be undertaken by me at my sole risk. That I am in good health and have no physical conditions that would be aggravated by my involvement in cardiovascular exercise, weight lifting, weight training and/or body building, nor do I have any physical limitations that would preclude said involvement. I also release Wired Fitness, its contractors (the personal trainers), and the Cities of Chula Vista, San Diego, and Encinitas from liability for their negligence, defective equipment, injuries from dangerous conditions of property, etc.

HAVING READ THE ABOVE TERMS AND INTENDING TO BE LEGALLY BOUND HEREBY AND UNDERSTANDING THIS DOCUMENT TO BE A COMPLETE WAIVER AND DISCLAIMER IN FAVOR OF WIRED FITNESS OF ANY AND ALL LIABILITY, I HEREBY AFFIX MY SIGNATURE HERETO.

Additional Policies: You will be asked to read, know, and sign a 'Policies and Procedures' web-based document at the time of enrollment. These policies will be enforced throughout your term and should be followed to ensure focus is maintained on your goals. Emergencies, freezes and special consideration will be handled at the trainer’s discretion. Before and after pictures may be requested. Photographers may be present during class time photographing for our ‘Photo Gallery’ and for advertising and media purposes. Please let the trainer know if you have any concerns.

Type FULL Name (if under 18, parent must complete this and place their name in this box) *

Date Signed *

MM / DD / YYYY