History and Waiver Form
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Name: *
Cell Phone: *
Email: *
Address: *
Date of Birth: *
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DD
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Gender: *
Height: *
Weight:
Occupation: *
Emergency Contact (Name and Phone Number): *
Physician's Name:
Physical Therapist's Name:
How did you hear about Infinity Fitness? *
Referred By:
Have you done any of the following activities? (Check any/all that apply): *
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What are your current fitness goals? *
What are you doing right now to reach those goals? *
Do you have any injuries, aches, pains, recent surgeries or issues that we should know about? (Don't be shy; we've all got issues...) *
What would you like to see change in the next 90 days? *
I hereby voluntarily consent to engage in a fitness program with Infinity Fitness. I understand that in rare instances physical exercise can cause, among other things, dizziness, chest discomfort, nausea, and joint or muscle soreness. I agree to assume all risks involved and hereby release all employees/staff from any and all health claims, suits, losses, or causes of action for damages, injury or death, including claims for negligence, arising out of or related to my participation in a fitness program or assessments. I have read the foregoing carefully, and I understand its content. Any questions that may have occurred to me concerning this informed consent have been answered to my satisfaction. *
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