Fitness Together - Sacramento, CA

Registration Form

Name:
Date:
Birthday:
Height:
Weight:
Goal:
Street Address:
City:
Zip:
Email Address:
Phone(s):	(Home) (Work) (Cell)
Work Address:
How did you hear about our Bootcamp?
If Other:
REFUND POLICY: All sessions are paid in advance and are held as credits to your account. These credits cannot be redeemed for cash value and are non-refundable and non- transferable to another individual. If 30 consecutive days pass with no activity to your account, unused sessions will be forfeited. There is no refund for unused sessions ( except for death, disability (permanently restricting exercise) however missed sessions may be made up at the next Boot Camp, with the owner’s consent.) PARTICIPANT’S AGREEMENT, RELEASE AND ACKNOWLEDGEMENT OF RISK. It is recommended that you consult with your physician before beginning or modifying any exercise regime. 1. I warrant that I am in good health and that I have notified the club of any pre-existing medical conditions that I have. 2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary and I elect to participate in spite of the risks. 3. I hereby voluntarily release, forever discharge and agree to indemnify and hold harmless, Fitness Together (hereinafter collectively referred to as “FT”), for any and all claims, demands or causes of action, which are in any way connected with my participation in this activity or my use of FT’s equipment or facilities, including any such claims which allege the negligent acts or omissions of FT. 4. Should FT, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs and assume full responsibility for those cost. 5. In the event that I file a lawsuit against FT, I agree to do so solely in the state of California, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. My signature below, acknowledges that I have read, understand, and agree to the above terms.
Name Signature:
Date:
Sign me up for:	Bootcamp I (4 sessions $85) Every Saturday beginning May 17th
Complete and fax or email: davevonruden@fitnesstogether.com or fax 916-515-3970 or call 916-515-3940
Please charge my payment to my (check one):	Visa Mastercard American Express Discover Card
Credit Card Number:
Expiration Date:
Name on Card:
Billing Address:
I authorize the above company and Vanco Services, LLC to charge my credit card in accordance with the information above.
Signature (as it appears on the credit card):
Date:
HEALTH QUESTIONAIRE
Please List Any Injuries or Operations That May Restrict Exercising:
MEDICATIONS:
PAR-Q	*Circle which applies to you.*
Yes No	Has your doctor ever said that you have a heart condition and should restrict physical activity?
Yes No	Do you feel a pain in your chest when you do physical activity?
Yes No	In the past month, have you had chest pain when you were not doing physical activity?
Yes No	Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes No	Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes No	Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Yes No	Do you know of any reason why you should not do physical activity?
Yes No	Do you have any personal history of metabolic disease (thyroid, renal, liver)?
Yes No	Have you had diabetes for less than 15 years?
Yes No	Have you had diabetes for 15 years or more?
Yes No	Have you experienced pain or discomfort in your chest apparently due to blood flow deficiency?
Yes No	Any unaccustomed shortness of breath (perhaps during light exercise)?
Yes No	Have you had any problems with dizziness or fainting?
Yes No	Do you have difficulty breathing while standing or sudden breathing problems at night?
Yes No	Do you suffer from ankle edema (swelling of the ankles)?
Yes No	Have you experienced a rapid throbbing or fluttering of the heart?
Yes No	Have you experienced severe pain in leg muscles during walking?
Yes No	Do you have a known heart murmur?
Yes No	Do you have any family history of cardiac or pulmonary disease prior to age 55?
Yes No	Have you been assessed as hypertensive on at lease 2 occasions?
Yes No	Has your serum cholesterol been measured at greater than 240 mg/dl?
Yes No	Has your HDL (the "good" cholesterol) been measured at greater than 60 mg/dl?
Yes No	Are you a cigarette smoker?
Yes No	Would you characterize your lifestyle as "sedentary"?
I have read and have answered all the questions above accurately and honestly. I believe I am in good health and able to attend the Boot Camp.
Signature:
Date:
I authorized FT-Natomas to use any photos/video taken of me at the bootcamp for promotional purposes.
Initial:
Date:

Fitness Together - Sacramento, CA
2121 Natomas Crossing Drive Ste. #400, Sacramento, CA 95834
Phone (916) 515-3940