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PAR-Q/ Goal Form
Name
*
First
Last
Your Age
Email
*
Physical Activity Readiness
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you perform physical activity?
Yes
No
In the past month, have you had chest pain when you were not performing any 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 any medication for your blood pressure or for a heart condition?
Yes
No
Do you know of any other reason why you should not engage in physical activity?
Yes
No
If you have answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered YES to. After medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
Occupational
What is your current occupation?
Does your occupation require extended periods of sitting?
Yes
No
Does your occupation require repetitive movements?
Yes
No
Discuss repetitive movements
Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?
Yes
No
Does your occupation cause you mental stress?
Yes
No
Recreational
Do you partake in any recreational physical activities (golf, skiing, etc.)
Yes
No
Please discuss activities:
Do you have any additional hobbies (reading, video games, etc.)?
Yes
No
Please discuss hobbies:
Medical
Have you ever had any injuries or chronic pain?
Yes
No
Discuss injuries or chronic pain
Have you ever had any surgeries?
Yes
No
Discuss surgeries
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes?
Yes
No
Discuss diagnoses
Are you currently taking any medication?
Yes
No
Please list medications
Goals
Please select all goals below that apply to you
Lose Body Fat
Develop Muscle Tone
Rehabilitate an Injury
Education
Start an Exercise Program
Sports Specific Training
Increase Muscle Size
Fun
Motivation
What is your current fitness routine, if any?
What are your favorite formats of exercise?
What are you least favorite formats of exercise?
Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months
Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, etc.)
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Agreement Form
Name
*
First
Last
Email
*
Congratulations on your decision to participate in an exercise program. Together, we will improve your ability to accomplish your training goals faster, safer, and with maximum benefits. In order to maximize progress, it will be necessary for you to follow program guidelines during supervised and (if applicable) unsupervised training days. Remember, exercise and healthy eating are EQUALLY important!
Personal Training Terms and Conditions
• Personal training sessions that are not rescheduled or canceled 24 hours in advance (with emergency exceptions) will result in a session full rate fee.
• Payment is due at the completion of each session (cash, check, Venmo, Zelle, Chase QuickPay)
• Clients arriving late will receive the remaining scheduled session time, unless other arrangements have been previously made with the trainer.
I agree to the terms. Please initial here:
*
Dated
MM slash DD slash YYYY
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Fitness Waiver /Release Of Liability
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WAIVER AND RELEASE OF LIABILITY: DDB Fitness LLC In consideration of the risk of injury while participating in Personal Training (the "Activity"), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge DDB Fitness LLC, located at 189 Schermerhorn St PHB, Brooklyn, New York 11201, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity. I acknowledge that I have carefully read this "Waiver and release" and fully understand that it is a release of liability. I expressly agree to release and discharge ddb fitness llc and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against ddb fitness llc for personal injury or property damage. I agree to indemnify and hold harmless DDB Fitness LLC against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If DDB Fitness LLC incurs any of these types of expenses, I agree to reimburse DDB Fitness LLC. I acknowledge that DDB Fitness LLC and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of DDB Fitness LLC. I acknowledge that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic and actions of others, including but not limited to, participants, volunteers, spectators, coaches, event officials and event monitors, and/or producers of the event. I acknowledge that I have carefully read this "Waiver and release" and fully understand that it is a release of liability. I expressly agree to release and discharge ddb fitness llc and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against ddb fitness llc for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of DDB Fitness LLC, its agents, and employees. In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. In the event that any damage to equipment or facilities occurs as a result of my or my family's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness. This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength.
Emergency Contact 1
Name
First
Last
Relationship to You
Phone
Emergency Contact 2
Name
First
Last
Relationship to You
Phone
Emergency Contact 3
Name
First
Last
Relationship to You
Phone
Signature
I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.
Both the Participant, and DDB Fitness LLC agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into. In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited. In the event of an emergency, please contact the following person(s) in the order presented:
Signature
Name
*
First
Last
Email
*
Date
*
MM slash DD slash YYYY
Please initial here
*
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