Intake Form

Congratulations! You are making a commitment to invest in your health and well-being.

In order to assess your general health risk and tailor the training process to your individual needs, you will be asked questions about your, and your family’s, health history. Your privacy is respected. Your information will never be shared without your advanced written consent (except in the event of a medical emergency) and will not be used for any purpose other than adjusting your fitness training program and assessing your health risk as it pertains to your training. An educated trainer is better able to help you safely meet your goals.

I am interested in participating in...

Today's Date (required)

Name (required)

Age (required)

Address

City

State

Zip

Phone Number

Your Email (required)

Gender (choose all that apply):

Do you have a history of any injury or surgery? (required)

Does the above injury/surgery still affect you? Please describe or reply N/A

Choose All or Any That Apply

Describe Other Concerns from Above Here

Emergency Contact #1 (required)

Name:

Relationship:

Phone:

Emergency Contact #2 (optional)

Name:

Relationship:

Phone:

What is your current health/fitness goals?
(i.e. weight loss, look better, be healthier, improve performance, make better dietary choices)

What is your occupation?

Activity Level

Height (optional)

Weight(optional)

Resting Heart Rate [beats per minute] (optional)

Describe your fitness background. (i.e. high school sports, 5K, weight lifting, jazzercise, daily walking)

Tshirt Size:

Proper diet and exercise is important for a long, active and healthy life. The training sessions will involve mild, moderate or even strenuous exertion of your physical body. Intensity will be monitored by the trainer and customized to your health and tolerance. However, any physical activity can result in injury or death for reasons beyond the control of the trainer. Your signature below acknowledges you agree to be honest and forthcoming by reporting any medical history, conditions or injuries that may increase your risk of further injury, illness or death. You also acknowledge that physical activity, including but not limited to, running, weightlifting, and other aerobic and anaerobic activities are inherently dangerous and can result in injury or death and trainers and coaches associated with "Weights 'n' Plates" are not liable for injury to your person or property. Communicate whenever you are uncomfortable or in pain so your activity can be modified for your health and safety.

By clicking SUBMIT you acknowledge your understanding and consent and agree that the information you have provided is true to the best of your knowledge.