EmailMe Form - Over40 Fitness Registration

Name *

First Last

Address

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

Mobile Phone *

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

Email *

How did you hear about Over 40 Fitness? *

Client Referral or Explanation?

Package Type

Please choose which Training or Nutrition package you are interested in.

Package Options: *

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

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 Over 40 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 Over 40 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 Over 40 Fitness, and the operator of Over 40 Fitness, and from my use of Over 40 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 Over 40 Fitness, its contractors (the personal trainers), 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 OVER 40 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.

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

Date Signed *

MM / DD / YYYY