Please Complete Our Initial Consultation Form Name * First Name Last Name Email * Date of Birth * MM DD YYYY Select Your Trainer * Any Trainer Alan Amy Andrew Bert Brian Cary Jack Leah Lindsay Ray Reese Ryan Sajan Sarah Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 to 69, the Par-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly. 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? * Yes No 2. Do you feel pain in your chest when you do physical activity? * Yes No 3. In the past month, have you had chest pain when you are not doing physical activity? * Yes No 4. Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No 5. Do you have a bone or joint problem (for example, back, neck, knee, or hip) that could be made worse by a change in your physical activity? * Yes No 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? * Yes No 7. Do you know any other reason why you should not do physical activity? * Yes No If you answered YES to any of the questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want—as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which community programs are safe and helpful to you. NO to all questions NO to all questions: If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.- take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active. By checking this box, you agree that you have read, understood and completed this questionnaire. Any questions you had were answered to your full satisfaction. * I agree Guest and Member of ProFormance Liability Waiver By checking the box below I understand and voluntarily accept this risk and agree to specifically assume all risk of injury, whether physical or mental, while I am using or present at any of ProFormance’s locations, using any of ProFormance’s equipment or services or participating in or adhering to ProFormance’s programs, whether such programs take place inside or outside of the ProFormance locations. I waive any and all claims or actions that may arise against ProFormance, its owners, directors, employees or volunteers as a result of any such injury to any such person, including and without limitation, personal bodily or mental injury, economic loss or any damages resulting from the negligence of ProFormance or anyone else at a ProFormance location. If there is any claim by anyone based on any injury, loss, or damage that involves me, I agree to defend ProFormance against such claims and pay knowingly and willingly that I have enrolled in a physical fitness program that includes, but is not limited to, running, jumping, stretching, strength training, and exercising in different locations in and around Louisville, KY or anywhere the participant is exercising. In consideration of my entry and of my own free will, I the undersigned, do hereby for myself and my heirs, executors and administrators, waive and release and give up any and all claims demands, liability, damages, costs and expenses of any kind whatsoever including personal injury to me or my wrongful death against Proformance, ProFormance instructors and any persons involved in the program and all of its affiliates that may arise from my participation in ProFormance activities or while traveling to and from the classes, even if caused in whole or in part by the negligence or other fault of the aforementioned parties or persons. I fully understand that I may injure myself as a result of my participation in this program and hereby release Proformance, and aforementioned facilities from any liability, now or in the future, including but not limited to heart attacks, muscle strains, sprains, tears, broken bones, shin splints, heat exhaustion, knee, back, or foot injuries and any other illness, soreness or injury, however caused, occurring during or after my participation in this exercise program. It is further agreed that all exercises including the use of equipment, as well as travel to and from ProFormance locations shall be AT MY OWN RISK. This waiver applies to every county/state/country. I FULLY UNDERSTAND THAT I AM FOREVER GIVING UP, IN ADVANCE, ANY RIGHT TO SUE OR MAKE CLAIMS AGAINST PARTIES I AM RELEASING, IF I SUFFER ANY INJURIES OR DAMAGES, EVEN THOUGH I DO NOT KNOW WHAT OR HOW EXTENSIVE THOSE INJURIES AND DAMAGES MIGHT BE AND AM VOLUNTARILY ASSUMING THE RISK OF SUCH INJURIES OR DAMAGES. I UNDERSTAND THIS CONSENT FORM AND AM NOT UNDER ANY PHYSICAL OR EMOTIONAL DURESS TO SIGN. * * I agree 24-Hour Cancellation Policy By checking the box below I agree to adhere to the ProFormance 24-hour cancellation policy. This policy requires that your ProFormance Personal Trainer receive the courtesy of notice of cancellation of 24-hours prior to the scheduled session due to the high demand of our trainers. If notice of cancellation is given less than 24-hours prior to the scheduled training appointment, or no notice is given, then the client signing below agrees to pay for the canceled session. All fees are non-exchangeable and non-refundable and must be paid by the end of each session. Make checks payable to ProFormance LLC. I agree to all of the terms as stated above and understand that this agreement can be terminated at any time by the client or, at the end of paid training sessions, by ProFormance. * * I agree Thank you!
