MCL Gym intake form : Live By Living

*Your name

*Your email

*Address

*City

*State

*Postal

*What is your birthdate?

*What is your doctor's name? (preferably your oncologist, if you are still in treatment)

*Does your doctor know you are participating in an exercise program?

Yes No

*What, if any, restrictions does your doctor suggest? If none, say "none."

Who is your emergency contact?

*What is your emergency contact's phone number?

*Are you taking any medications?

Yes No

*Please list any medications you are taking

Please describe your current fitness routine. (it's OK if you don't have one)

*Have you ever had high blood pressure?

Yes No

If you have had high blood pressure, what guidelines did you get regarding exercise?

*Have you ever been diagnosed with cancer?

Yes No

If you have been diagnosed with cancer, please tell me the kind, date of diagnosis (month/year is fine), and describe your treatment.

How many lymph nodes did you have removed?

If you checked other, please describe.

*Is there anything else you want me to know? If not, just say "no."

*Client printed name

Guardian printed name

BY SIGNING BELOW, I CERTIFY THAT I HAVE GIVEN FULL AND COMPLETE DISCLOSURE OF ALL PHYSICAL CONDITIONS, LIMITATIONS, DISEASES, INFIRMITIES, AND/OR ILLNESSES THAT MAY AFFECT OR PREVENT MY PARTICIPATION IN THE PERSONAL TRAINING SESSIONS.

LIABILITY WAIVER AND RELEASE
I have agreed to voluntarily participate in a remote video exercise program, including, but not limited to, strength training, flexibility development, and aerobic exercise, under the guidance of Terri Ross/Move Conquer Live, LLC (hereafter referred to as Fitness Professional/Facility). I hereby stipulate and agree that I am physically and mentally sound and currently have no physical conditions that would be aggravated by my involvement in an exercise program.
I understand and am aware that physical-fitness activities, including the use of equipment, are potentially hazardous activities. I am aware that participating in these types of activities, even when completed properly, can be dangerous. I agree to follow the verbal instructions issued by the trainer. I am aware that potential risks associated with these types of activities include but are not limited to: death, fainting, disorders in heartbeat, and serious neck and spinal injuries that may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my body, general health, and well-being. I further agree and warrant that if at any time I have questions or feel unsafe, I will immediately discontinue further participation in the activities.

I will provide any equipment to be used in connection with workouts, including but not limited to, benches, dumbbells, barbells and similar items. I represent and warrant any and all equipment I provide for training sessions is for personal use only. The Fitness Professional/Facility has not inspected my equipment and has no knowledge of its condition. I understand that I take sole responsibility for my equipment.

I further understand that to the extent any activities take place via Zoom or other virtual platform, Fitness Professional/Facility cannot guaranty the quality of the transmission or continued connection during the activities.

I do hereby assume full responsibility and hold Terri Ross, Move Conquer Live, LLC, Live By Living, and their agents, owners, successors, assigns, employees, directors, and other related individuals and entities, harmless for any and all damages, injuries (including death), or losses that I may sustain or incur, if any, while attending, practicing, participating or witnessing in any exercise program, sport or physical activity offered by Move Conquer Live, LLC.
This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of Colorado. Any and all actions, suits, or judicial proceedings upon any claim arising from or relating to this Agreement shall be instituted and maintained in the State of Colorado, County of Denver shall be the venue.

My signature is proof of my intention to execute a complete and unconditional waiver and release of all liability to the fullest extent of the law. I am at least 18 years old and am mentally competent to enter into this agreement. (If I am not at least 18 years old, my parent or guardians signature certifies my intention.)

I HAVE CAREFULLY READ, CLEARLY UNDERSTAND AND VOLUNTARILY SIGN THIS USE, WAIVER AND RELEASE AGREEMENT.

*Signature of client or guardian

Clear