Forms

Does your physician know that you will be participating in an exercise program? *

Yes No

Does he/she give you their clearance to do so? *

Yes No

Physician's Information: Name - Address - Phone *

In Case of Emergency, Contact: Full Name - Phone - Alternate Phone *

Do you have an Allergies *

Yes No

If yes, please list *

Do you have any history of dizziness, light-headedness, or fainting? *

Yes No

If yes, please specify the cause *

Are you on ANY medication (including over-the-counter preparations)? *

Yes No

If yes, Name and Reason *

Are you taking any Vitamins, Supplements, etc.? *

Yes No

If yes, Name and Reason *

If yes, please explain: *

Are you pregnant? *

Yes No

Do you smoke *

Yes No

Please list any serious illnesses or hospitalizations and dates: *

Please list any surgeries and dates: *

Please list ANY orthopedic concerns, past or present. Knee pain, back pain, broken bones, etc. *

How often do you exercise? When was the last time you exercised *

What type of activity do you usually participate in? (Please be specific and give examples) *

What are your goals for your exercise program? (Short-term and long-term) What would you like to accomplish?) *

What do you find motivates you to exercise? *

What are some de-motivating factors for you? *

Whom can we thank for this referral? *

CONSENT TO PARTICIPATION. I hereby certify that the information is true to the best of my knowledge. I understand that Emerge Athletics Ltd. may require medical clearance before I am able to engage in any physical activity under their guidance. I understand that it is my responsibility to inform Emerge Athletics Ltd. of any change in medical status. I understand the nature and purpose of the Medical History and Health Appraisal and I am aware that any strenuous physical activity involves risks. Accordingly, I release, discharge, absolve, and hold harmless Emerge Athletics, its directors, officers, employees, agents, and representatives from any accident, injury, or loss sustained by me as a result of activities at present of Emerge Athletics Ltd.’s staff except for any accidents, injuries, or losses sustained as a gross negligence and willful misconduct of the trainer. I have volunteered to participate in a fitness program of progressive physical exercise offered by Emerge Athletics Ltd. In consideration of my participation in this exercise program, I, for myself, my heirs and assigns, hereby release Emerge Athletics Ltd., its directors, officers, employees, agents, and representatives from any claims, demands, and causes of action arising from my participation in the exercise program. I waive any claim or cause of action for any personal damage or injury which I may sustain, whether occurring during or after my participation in the exercise program and which may be blamed upon or allegedly be a result of such a program. I am aware that I am entering a general wellness program. Participant takes full responsibility for the level and types of aerobic exercises and activities selected. To my knowledge, I do not have any limiting medical condition that may preclude or limit my participation in an exercise or cardiovascular program and I accept full responsibility for my participation in the program. The possibility of certain unusual changes during exercise does exist. They include: abnormal blood pressure, fainting, disorders of the heart beat, and in very rare instances, heart attack. I hereby acknowledge my acceptance of these risks. I have been informed of the value of a physician’s approval for participation in a fitness program. I fully understand the strenuous nature of the program being offered. I accept complete responsibility for my health and well-being in the voluntary exercise-fitness program and understand that no responsibility is assumed by Emerge Athletics Ltd. *

I AGREE

CANCELLATION POLICY. Notice of cancellation is required 48 hours or more before any scheduled session. Emerge Athletics reserves the right to forfeit the fee for any session which is cancelled less than 48 hours before the scheduled time. *

I AGREE

TERMS. Personal Training Memberships expire at the end of each month regardless of whether all sessions have been completed. No make-up sessions offered after expiration date. Refunds not available. Payment due before the first session. *

I AGREE

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Medical History and Health Appraisal