*Name:

 

Address:

 

City:

 

State:

 

Zip:

 

Profession:

 

Country:

 

Date of Birth:

 

(mm/dd/yyyy)

Home Phone:

 

    Work Phone:

Fax Number:

 

Mobile Number:

*Email:

 

Fitness Level:

 

Referred by:

 

How did you hear about us:

 

Specific Referral:

 

First Camp:

 

Yes No

*Emergency Contact:

 

*Emergency Number:

 

Program:

 

Payment Type:

 

Tee Shirt Size:

 

Allergies:

 

YesNo

Allergy List:

 

Currently on Medications:

 

YesNo

Medications List:

 

Has Epilepsy:

 

YesNo

Has Diabetes:

 

YesNo

Diabetes Medications:

 

Is Anemic:

 

YesNo

Has Hypertension:

 

YesNo

Hypertension Medications:

 

Heart Disease History:

 

YesNo

Lung Disease History:

 

YesNo

Kidney Disease History:

 

YesNo

Liver Disease History:

 

YesNo

Has Asthma:

 

YesNo

Asthma Medications:

 

Neck Injury History:

 

Been Knocked Out:

 

Wears Eyeglasses:

 

YesNo

Has Broken Bones:

 

Back Injury History:

 

Do you have Back Pain:

 

YesNo

Knee Injury History:

 

Other Pain History:

 

Surgical Procedures:

 

Goals:

 

Been Fat Tested: 

 

YesNo

Fat Tested Percent: 

 

%

Is Training:

 

YesNo

 

Agrees to Terms: 

I agree to show up for Fit Club every day unless it is an excused absence from my doctor or pre-approved by my Fit Club Coach.

I understand that photos or video may be taken during the course of my involvement in Fit Club, which may be used for promotional purposes.

I understand that my "before & after" photos will not be used for any promotional purposes unless I give written authorization.

I understand there is a no refund policy after classes begin but I can receive a credit (for unused portion) towards other Fit Club products and services. I

understand that in order to be eligible for a credit, I must not be able to participate due to illness or disability and have a physician’s note.  I also understand

that I must notify my Fit Club Coach of my inability to complete class prior to the end of the session for which I originally signed up.  I  further understand that

if I am not able to participate in the class for reasons beyond my control and I notify my Fit Club Coach prior to the start of class, I will be

refunded my registration fee minus a $50.00 cancellation fee.

I will remember to set my alarm and be on time for all of my workouts.

I understand that diet and nutrition will affect my fitness goals and performance during Fit Club.  I will give 100% effort in following the nutrition

guidelines provided to me.

I will arrive with a positive attitude and expect to have fun and give 100% effort for each workout!

 

Signature                                                                                 

 

Date