Phenom Strength and Conditioning Sign Up
Client Information Sheet
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Name *
Birth Date *
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Address
Street
City
Social Networks You Belong To *
Check all that apply
Required
Zip Code
State
Emergency Contact Information
Athlete's Cell Phone Number (under 14 Parents) *
Athlete's Home Phone Number
Email Address
Name of Athlete's Legal Guardian
Contact Number For Legal Guardian
Second Contact Number for Legal Guardian
Insurance Provider Name
Subscribers Contact Number
Medical Information
Primary Physician
Primary Physician's Address
Primary Physician's Contact Number
Date of Last Physical Examination
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Please list any medications you are currently taking. (including over the counter)
Please list any major illness, hospitalization, or surgical procedures that occurred within the past 2 years.
Please list any allergies to foods and or drugs.
Check any of the following conditions which apply to you. *
Required
Are you currently under the care/treatment and referral from a medical doctor? *
If Yes Please refer to the front desk for additional medical paperwork.  If necessary, HIPPA documentation gives Phenom Strength & Conditioning permision to receive medical documents, images, etc. from physicians.
Effective Date *
Today's Date   ---This agreement, made effective on the below date between Phenom Strength & Conditioning LLC and Client (and/or party responsible for client if less than 18 years of age.)
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I The Client agree to the cost of services presented to me and understand that these costs are valid for the work to be performed at this given time.  Cost of service may change over a period of time should i request similar service at a later date.  I fully agree to and have read the company policies and procedures.  The payment and refund policies have been explained and presented to me in a clear manner of which I completely understood.  I agree to pay for the service when rendered or in advance if required.  at this time, I also agree to train a Phenom Strength and Conditioning for only the amount of time purchased.  I understand once i have used up the service upon purchase that I am neither obligated nor committed to continue unless chosen by me through the repurchase of additional services. *
Print Your Full Name Below As Your Signature
Confidentiality Agreement
I understand that my person and medical information will not be distributed outside of Phenom Strength & Conditioning. The information gathered is solely used to benefit my health and physical performance. I am aware that the staff will use the quantitative statistics from my training for research and analysis towards the improvement of physical training. My name of personal statements towards Phenom Strength & Conditioning will not be used unless I have provided written approval for special circumstances to the staff of Phenom Strength & Conditioning. Photographs or videos taken in house by the staff will remain in a secured area and will only be shared between the staff of trainer(s) and myself. I understand that any paperwork provided to me by the staff of Phenom Strength & Conditioning concerning training, nutrition, and education is proprietary information from Phenom specific to my individual needs. I understand that redistributing this information for profit or for any other reason to other parties is prohibited without the consent of Phenom.   *
Print Your Full Name Below As Your Signature
Waiver and Release
I (client) acknowledge that any program of physical exercise involves a risk of injury. I have voluntarily chosen to participate in a program of progressive exercise. In signing  this document I acknowledge being informed of the strenuous nature of the program and the program and the potential for unusual, but possible, physiological results  including, but not limited to, abnormal blood pressure, fainting, heart attack and death.  I have been recently examined by a medical physician and been found able to undertake a program of exercise.  For and in consideration of the design of an exercise program I, the client, agree:  1. That any exercise program shall be undertaken by client at his or her sole risk  2. That trainer shall not be liable to client nor any other person for any claims or causes of action  3. The client hereby releases and discharges trainer from any such claims or actions *
Print Your Full Name Below As Your Signature
Phenom Rules/Regulations
Click Here to View:  http://goo.gl/w4KJFC
I Have Read the Rules/Regulations and Agree To Comply To The Best Of My Ability. *
Print Your Full Name Below As Your Signature
Photographic/Videographic Likeness Consent
Photographic/Videographic Likeness Consent Form  By signing below I give Phenom Strength and Conditioning permission to use my photographic likeness, in promotional publications, educational publications, display and in other media.  I grant permission to Phenom Strength and Conditioning to use, reproduce, distribute and/or publicize my photographic likeness.  Publication, use and distribution of my photographic likeness may be by any means and without limit. Publication or use may occur in any media, including newspapers; magazines, television; brochures; pamphlets; instructional material; books; Internet, web pages, and educational material. I acknowledge that I understand that Phenom Strength and Conditioning intends to use my photographic likeness for educational and promotional purposes. This agreement is binding on successors, assigns and/or heirs. *
Print Your Full Name Below As Your Signature
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