Please compete only if instructed to prior to the start of your personal training session or FitCamp participation.  Answer all questions accurately and honestly and we can get started on your fitness program.

First Name  
Last Name  
1. Sex: FemaleMale
2. Age:
3. Weight lbs.
4. Height feet inches
5.How much weight do you feel you need to lose or gain? lbs.
6. Describe your exercise program:
7. Describe your fitness goals:
8. List your favorite foods
9. List your least favorite foods
10. Do you snack? YesNo

Please Describe:

11. Do you like to cook? YesNo
12. What you have you done in the past to lose or gain weight?
13. How often do you eat out per week? 

Where:

14. What is your occupation?

                                  

15. How much sleep do you get? hours
16. On a scale of 1 to 10, how important is it to achieve your goal?
17. Medical information Do you currently or have you within the past year experienced (check all that apply):

1. Heart Problems?

2. High blood pressure?

3. Frequent pains in your heart or chest?

4. Any chronic illness?

5. Repeated fainting or severe dizziness?

6. Been advised by a physician not to exercise?

7. Surgery?

8. Lung Problems?

9. Diabetes?

10. Smoke cigarettes?

11. High blood cholesterol?

12. Arthritis?  

13. Epilepsy?                                            

14. Back Problems?

15. Taking medication?

16. Pregnant?

18. Do you have any injuries (chronic or acute) that I should be aware of before your participation in our fitness programs?
19. Comments:
Activity Release Agreement

I am voluntarily participating in an athletic activity with Kevin LaCourte, KL Fitness, L.L.C. (hereinafter referred to as "Released Parties") with full knowledge and understanding and appreciation of the risks of injury inherent in any physical exercise, massage or therapy program, physical activity or athletic activity and expressly assume all risks of injury and even death which could occur by reason of my participation. I release company and trainer from any liability and agree not to sue company or trainer with respect to any cause of action for bodily injury, property, damage, or death occurring to me as a result of my participation in the activity.

In consideration of the use of the property, facilities, services, programs, activities and events provided by Released Parties in California, Florida and any other location, including any travel related thereto, the undersigned agrees as follows:

1. RISK FACTORS. The undersigned understands and acknowledges that the use of equipment and facilities provided by Released Parties, and participation in Fitness Programs, Physical Sports, Weight and Cardiovascular training, and any other programs and services provided or sponsored by Released Parties, and related travel, involves risk such as, but not limited to, the following which might result from the use of the equipment or facilities, from the activity itself, from the acts of others, or from the unavailability of emergency medical care: RISK OF PROPERTY DAMAGE, BODILY INJURY including, but not limited to, shin splints, knee injuries, foot injuries, back injuries, muscle strains, sprains, broken bones, skin rash, stroke, heart failure, dehydration, AND POSSIBLY DEATH.

2. ASSUMPTION OF THE RISK. The undersigned ASSUMES ALL RISKS WHICH ARE FORESEEABLE AND INVOLVED WITH OR ARISE OUT OF THE USE OF THE EQUIPMENT OR FACILITIES, THE ACTIVITY ITSELF, THE ACTS OF OTHERS, OR THE UNAVAILABILITY OF EMERGENCY CARE, including but not limited to, those RISK FACTORS described in Section 1 above.

3. PREREQUISITE SKILLS AND TRAINING. The undersigned acknowledges that he or she has the requisite skills, qualifications, physical ability and training necessary to properly and safely use the equipment and facilities and to participate in the activity itself. The undersigned agrees that if he or she has any questions as to what skills, qualifications or training is necessary to properly use the equipment, facility, or participate in any class activity, then they shall direct such questions to the appropriate Staff Member on site.

5. RELEASE. The undersigned RELEASES Kevin LaCourte and all of his employees and agents and agrees NOT TO SUE Kevin LaCourte on account of, or in conjunction with, any claims, causes of action, injuries, damage, or cost of expenses arising out of the activity, including those based on death, bodily injury or property damage whether or not caused by the negligence or other fault of the parties being released.

6. WAIVER. The undersigned waives the protection afforded by any statute or law in any jurisdiction whose purpose, substance and/or effect is to provide that a general release shall not extend to claims, material or otherwise which the person giving the release does not know of suspect to exist at the time of executing the release. This means, in part, that the undersigned is releasing unknown future claims.

I also understand all personal property brought to exercise location, is brought at my sole risk as to theft, damage or loss.

DISCLAIMER: As per the Electronic Signatures in Global and International Commerce Act of the United States of America, the signature below states your full acceptance of all terms and conditions laid forth in the above mentioned AGREEMENT.  Your text signature below indicates full acceptance of all TERMS and CONDITIONS of said AGREEMENT as of DATE listed.

Participant Signature:  
Date:   (Current Date)
Phone #:   (format: xxx-xxx-xxxx)
Verify Legal Name:   (Full Legal Name of Participant)
E-mail Address:   (Valid E-mail Address)
Emergency Contact   (Name of emergency contact)
Emergency Phone   (Emergency contact phone #)

By clicking the button below, you agree to the TERMS & CONDITIONS set forth above, and AUTHORIZE the above signature to be valid and legally binding.

If you DO NOT agree with the TERMS & CONDITIONS above, DO NOT CONTINUE, please contact Kevin LaCourte immediately at kl@kevintrains.com

 

 

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