EmailMe Form - WF Fitness Information Sheet

Are YOU ready to COMMIT 100%, NO Excuses, NO BS *

YES

NO

Name *

First Last

Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

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

Date Time *

MM / DD / YYYY

Current Weight *

Height *

Bodyfat % (if known)

Age *

Actvity

	Exercise Type	Times Per Week	Duration	Intensity
#1
#2
#3
#4

Lifestyle & Goals *

Describe Goals *

Workout Preference *

Explain Other Preference Above

Cardio Preference *

Explain Other Preference Above

Goal Weight or Body Fat % *

Has your doctor ever said that you have a heart condition and that you should
only perform physical activity recommended by a doctor? *

YES

NO

Do you feel pain in your chest when you perform physical activity? *

YES

NO

In the past month, have you had chest pain when you were not performing any
physical activity? *

YES

NO

Do you lose your balance because of dizziness or do you ever lose consciousness? *

YES

NO

Do you have a bone or joint problem that could be made worse by a change in
your physical activity? *

YES

NO

Is your doctor currently prescribing any medication for your blood pressure or
for a heart condition? *

YES

NO

Do you know of any other reason why you should not engage in physical
activity? *

YES

NO

If you answered YES to any of the above questions please explain in full detail below. All information will be kept confidential.

Additional Notes for your coach

PICTURES

These are a MUST for any coaching program.

Please take pics in a well lit area with a solid light or white background (no busy backgrounds). Same place, same time of day, same day each week, same outfit if possible.

Guys: Boxers, briefs, etc..
Ladies: Bikinis, sports bra and/or tight shorts.

These pics are meant to show detail of your body to help evaluate progress and losses in specific areas. So be as revealing as you feel comfortable currently.

Side #1 *

Side #2 *

Front View *

Back View *

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 (potential injuries, strains, sprains, and other potential health risks) 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 - e.g., injuries resulting from exercise equipment malfunction, negligence, etc.) 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 should be undertaken by me at my sole risk. That I am in good health, discussed your fitness program with a medical professional, 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.

Section Break

Please add your name, date and time, acknowledging the waiver above

Single Line Text *