Waiver and Release - Please Print
Personal Training Medical Questionnaire
Waiver and Release
Rules and Regulations
Medical Waiver and Release
Phone (h) ___________________ work _______________ cell ____________________
Medical Form - Medical Clearance
MEDICAL HISTORY QUESTIONNAIRE
Information considerations to consider before undertaking any type of exercise program are as follows:
Are you on any medications? _______, if yes, please list:
Do you smoke? _______
Do you have any physical problems that concern you? _______, if yes, please list:
Do you have any of the following:
Chest Pain (during exercise and/or rest? _______
Coronary heart disease? _______
Irregular heartbeats? _______
High blood pressure? _______
Family history of heart disease? _______
Rheumatic fever? _______
High cholesterol? _______
Respiratory problems? _______
Shortness of breathe? _______
Chronic cough? _______
Seizures or convulsions? _______
Severe headaches? _______
Serious bone, joint, or muscle injury? _______
Low back pain? _______
Surgery(s) - what, when, why, how many?
What does your physician recommend? ____________________________________
CONSULT YOUR PHYSICIAN BEFORE BEGINNING ANY EXERCISE PROGRAM
Waiver and Release
"I, ________________________, have enrolled in a program of strenuous physical activity including, but not limited to, traditional aerobics (low impact or high impact), weight training, stationary bicycling, and the use of various aerobic-conditioning machinery offered. I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit my participation in this exercise program."
"In consideration of my participation in personal training, offered by Loral Burke, I, _________________________, for myself, my heirs, and assigns, hereby release Loral Burke from any claims, demands, and causes of action arising from my participation in the exercise program."
"I fully understand that I may injure myself as a result of my participation in Loral Burke’s physical training program and I, ______________________, hereby release Loral Burke from any liability now or in the future including, but not limited to, heart attacks, muscle strains, pulls or tears, broken bones, shin splits, heart prostration, knee/lower back/foot injuries, and any other illness, soreness, or injury however caused, occurring during or after my participation in the exercise program."
Rules and Regulations for Personal Training Sessions - for Packages of 5 or More Sessions:
The expiration policy requires completion of an average of one session per week from the date of purchase. Unless arrangements have been made, client arriving late will only receive the remaining scheduled time for the session.
A "no show" will be charged for the session.
No refunds, unless the trainer cannot continue the sessions.
I hereby affirm that I have read and fully understand the above:
NOTE: If minor, below age of 18, please have parent or guardian sign above.