Loral's Personal Training and Fitness

- You Are Worth It!

Waiver and Release - Please Print 

 
 

Personal Training Medical Questionnaire

  Waiver and Release

Rules and Regulations

 

Medical Waiver and Release

Name _______________________________________________________________

Address _______________________________________________________________

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? _______

Diabetes? _______

Seizures or convulsions? _______

Severe headaches? _______

Obesity? _______

Arthritis? _______

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."

 

________________________________________

Signature

________________________________________

Date

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:

_______________________________________

Signature

____________________________________

Printed Name

____________________________________

Date

 

NOTE: If minor, below age of 18, please have parent or guardian sign above.