Please check the appropriate box for your desired membership
length: Please make sure when scheduling your free trial
class that you are able to attend. If you are unable to attend
you must communicate this with a member of our staff prior to
the class time. If you no show your free trial you will be forfeiting
the chance to test drive the class. We want to keep the focus
on serious and dedicated participants. If you are not ready to
commit to yourself please do not proceed.
Anticipated Start Date:
Classes per Week:
Preferred Location:
*Currently only TTH
**Taking interest only at this time
Full Name:
Primary Email Address:
Address:
City:
State:
Zip:
Primary Phone:
Alternate Phone:
Date of Birth:
(MM/DD/YYYY)
Body Weight:
Height:
Sex:
Fitness Goal (explain):
Private Physician:
Phone:
Emergency Contact and Phone:
Your Company:
Email (required):
Referred By:
*please explain
I,
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 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) 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 shall be undertaken by me at
my sole risk. That I am in good health 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 and its contractors
(the personal trainers) 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 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.
RISK ASSESSMENT
Have you ever had any form of heart disease?:
Have you ever experienced shortness of breath or chest pains?:
Date of last full physcial:
(MM/DD/YYYY)
Do you have or do any of the following pertain?
Please explain to the best of your ability?
High Blood Pressure:
High Cholesterol:
Cigarette Smoking:
Smoked in Past:
How long?:
Diabetes:
Insulin dependant?:
Family History of Heart Disease:
Who?:
Abnormal Resting EKG:
Are you active?:
Activity or Exercise:
Times per week:
Minutes per session:
Do you have any problems in the following areas?
Knee:
Yes
No Explain:
Low Back:
Yes
No Explain:
Neck/Shoulder:
Yes
No Explain:
Hip/Pelvis:
Yes
No Explain:
Flexibility:
Yes
No Explain:
Any other:
Yes
No Explain:
Are you currently taking any medication?:
Yes
No
Explain:
PAYMENT: There are No Administration or Membership
fees! All dues are payable on the 1st
of each month. **NO EXCEPTIONS**
Cash | Check | Credit Card Accepted
NOTE: Client
is required to terminate this agreement to discontinue automatic
renewal in writing for Credit Card payments. Any schedule changes
or additions need to be communicated before the 1st class day
of the month. All participants MUST complete and
sign a 'Policies
and Procedures' form prior to attending there 'Paid
Program.'
