Get StartedPlease fill out this brief questionnaire to get started:Name* First Last Today's Date* Phone*Email* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physicians Name* First Last Emergency Contact* First Last Emergency Contact Phone*Date of Birth* Does your physician know you're participating in this exercise program?* Yes NoAre you currently taking any medications/drugs?* Yes NoList them here:MedicationReasonDose Do you now, or have you in the past (select all that apply): History of or current heart problems, chest pain or stroke History of heart problems in immediate family Increased blood pressure High blood cholesterol Any chronic illness or condition Difficulty with physical exercise Advice from physician not to exercise Recent surgery (last 12 months) Pregnancy (now or last 3 months) History of or current breathing or lung problems Muscle, joint or back disorder Any previous injury still affecting you Diabetes or thyroid condition Cancer Smoking Osteoporosis Menopausal (pre, post) Overweight/Obesity (more than 20% over ideal body weight) Hernia, or any condition aggravated by lifting weightsPlease explain any items selection on the above list:Is there a health issue not mentioned in this questionnaire that would keep you from participating in regular exercise?Informed Consent and Liability Waiver Release for Participation in Exercise Program* I have read the below waiver and release of liability and fully understand it contents. I voluntarily agree to the terms and conditions stated.I agree and consent to the following: Fitness Class/Bootcamp exercise/fitness program conducted by Michele Meyer, Fitness for You, LLC. I recognize that the program requires physical exertion that may be strenuous at times and may cause physical injury and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the above-mentioned program. I represent and warrant that I have no medical condition that would prevent my participation in the program. I agree to assume full responsibility for any risks, injuries or damage know or unknown which I might incur as a result of participating in the program. Such injuries may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, injuries to back, injuries to foot, or any other illness or soreness, including death. I knowingly, voluntarily, and expressly waive any claim I may have against Fitness for You and Michele Meyer for injury or damages that I may sustain as a result of participating in the program. I, my heirs or representatives forever release waive, discharge and covenant not to sue Fitness for You or Michele Meyer for any injury or death caused by their negligence or other acts. Signature to confirm consent*Your NameYour NameCAPTCHAThank you for investing in YOU!
