We are committed to doing whatever it takes to help you achieve your goals. The more we know the better we will be able to deliver. Please take your time in completing this form and answer to the best of your ability.
Name *
Name
Address *
Address
Phone *
Phone
Emergency Contact
Emergency Contact
Emergency Phone *
Emergency Phone
Date of Birth *
Date of Birth
Billing Info
Billing Name
Billing Name
Billing Address
Billing Address
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *
Do you know of any other reason why you should not engage in physical activity? *
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.) *
Have you ever had any surgeries? *
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? *
Are you currently taking any medication? *
Waiver and Release *
I hereby consent to engage in physical training that may include cardiovascular, resistance, stretching and other vigorous activities (the "activity" or "activities" hereafter) offered by Willspace Training Inc. My participation in these activities is voluntary. I affirm that I do not suffer from any ailment that would be adversely affected by the activities. I affirm that all the information I have given pertaining to my current health status is reliable and accurate to the best of my knowledge. I understand that it is my responsibility to monitor my own condition throughout each training session and should anything unusual occur, I shall inform Willspace Training Inc. and consult with my physician. I hereby affirm that I am aware of the potential dangers and risks associated with the activities and therefore I agree to, subject to the foregoing paragraph, abide by all rules, guidelines and instructions provided by Willspace Training Inc. I hereby release, discharge, indemnify and hold harmless Willspace Training Inc., its agents and substitutes, from any claims, demands, and causes of action arising from my participation in the activities. I am legally competent to sign this release or my parent or guardian has read and signed this release and given me permission to sign it.
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