Name *
Address *
Email *
Telephone *
Age *
Weight *
Height *
Do you currently have any medical conditions? If yes please explain. *
Have you been hospitalized or had any major surgeries in the past year? If yes please explain. *
Are you pregnant, or have given birth in the last two months? *
Do you have a history or any of the following injuries or orthopedic problems? Check all that apply. *
Are you currently under a Doctors care? *
If under a Doctors Care have you been released to perform normal physical activities? *
Are you currently receiving physical therapy? *
Are you currently involved in any exercise program? If yes, please explain. *
to help design a program enjoyable to you, please select from the following list of activities all that are of interest to you. Check all that apply. *
How did you hear about or find Health Is Wealth Fitness Training?
I acknowledge to the best of my ability that I have answered the above questions completely and honestly and reaffirm that I have no known medical conditions that would restrict my ability to participate in any training chosen through Health Is Wealth Fitness Training programs. I also understand that any physical activity involves risk. Therefore, I do hereby waive, release and forever discharge the trainer, Brandon Mercado, from any and all responsibilities or liabilities from injuries and/or damages occurring as a result of my participation in any activities or use of equipment or machinery. By adding your name below you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
Today's Date *
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