Personal and Group Training Application

Welcome to Key Life Fitness and Training. We commend you on making the decision to take an active role in your health and wellbeing. We are dedicated to helping you take proactive steps towards reaching your goals, improving yourself, and your quality of life!
Please take a moment and fill out the information below!

COVID-19 Awareness Waiver
- I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
- I further acknowledge that Key Life Fitness and Bridget Jackson has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
- I further acknowledge that Key Life Fitness and Bridget Jackson can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to other clients and their families.
- I voluntarily seek services provided by Key Life Fitness and Bridget Jackson and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19.
- I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
  I attest that:
  - I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
  - I have not traveled internationally within the last 14 days.
  - I have not traveled to a highly impacted area within the United States of America in the last 14 days.
  - I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
  - I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
  - I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
  - I hereby release and agree to hold Key Life Fitness and Bridget Jackson harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the fitness center/trainer, or that may otherwise arise in any way in connection with any services received from Key Life Fitness and Bridget Jackson. I understand that this release discharges Key Life Fitness and Bridget Jackson from any liability or claim that I, my heirs, or any personal representatives may have against Key Life Fitness and Bridget Jackson.
Name

First Name Last Name
Signature

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Client/Trainer Responsibility Agreement
The guidelines that are outlined below are to ensure that the responsibility and relationship between the Trainer and the Client is clearly appreciated and understood.

Client’s Responsibilities:

It is very important that clients share all health history information and any medical concerns with the trainer. Keep in mind that you will need to notify your trainer about medications you are on. Any time new medications or diagnoses are given, it is imperative that you inform your trainer. Medications and certain conditions may pose significant risks to some types of training and your trainer must be aware in order to adjust your program safely and accordingly. If at any time during your workout, you feel discomfort or pain you must tell your trainer. Reaching your fitness goals is not always an easy accomplishment. It takes hard work and dedication. Your trainer will ensure correct exercise program development and technique; however, you must provide the commitment to give 100% of your energy and concentration to each session. This combination is to ensure your success!

Your payment for the Personal Training service must be made prior to your first training session. The time of this training session is agreed upon between the client and the trainer. If the client is late, the session will only last until the end of the hour for which that session was scheduled. If a session needs to be cancelled for any reason, a 24 hour notice must be given to the trainer by calling 954-257-4764. If prior notification is not given, that session will be forfeited.

Trainer’s Responsibilities:

Each training session is individually designed to meet your needs and goals and will last a maximum of 60 minutes. The personal trainer is there to create a workout program that is safe, effective, and conducive to reaching the goals that have been agreed upon by the client and trainer. If the trainer is late for a session, that time is owed to the client. If the trainer must cancel a session, the session is owed to the client. All information regarding your program and progress is confidential and will remain on file for 3 years following the cessation of your participation in the program. If you have any feedback regarding your trainer, or questions, please submit it in writing.

I understand and agree to the roles and responsibilities explained above:
Name *

First Name Last Name
Signature *

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Date *

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
1. Has your doctor ever said you have a heart condition and recommended only medically supervised physical activity? *
2. Do you have chest pains brought on by physical activity? *
3.Have you developed chest pain within the last month? *
4. Do you tend to lose consciousness or fall over as a result of dizziness? *
5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity? *
6. Has a doctor ever recommended medication for your blood pressure or for a heart condition? *
7. Are you aware, through your own experience or a doctor’s advice, of any other physical reason against your exercising without medical supervision? *
8. Are you pregnant? *
9. Do you know of any other reason why you should not do physical activity? *
Pre-Participation Screening - Cardiovascular Risk Factors
10. You take blood pressure medication. *
11. You are a man older than 45 years old. *
12. You are a woman older than 55 years old or have had a hysterectomy or you are postmenopausal? *
13. Do you smoke? *
14. Your blood pressure is greater than 140/90 or you have been told you have high blood pressure? *
15. Your blood cholesterol level is greater than 240/mg/dl or you have been told you have high cholesterol. *
16. You have a close blood relative who had a heart attack before 55 (father or brother) or before 65 (mother or sister). *
17. You are diabetic or take medicine to control your blood sugar *
*If two or more statements are checked in this section, the participant must have a referral from his/her doctor before being able to begin an exercise program.

Training Application/Questionnaire
Date
Name
Address
Primary Phone
Secondary Phone
Email
Date of Birth
Age
Age you feel
Date of Last Physical
Occupation
How did you find us?

How committed are you to achieving your fitness goals?

Very Semi Not Very
What do you think is the most important thing we can do to help you achieve your fitness goals?
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, allowing other responsibilities to become a priority over exercise etc.).
Outline 3 methods that you plan to use to overcome these obstacles:
Do you currently take any dietary supplements? YES / NO
Have you taken dietary supplements in the past? YES / NO *
Please rate your willingness to incorporate dietary supplements into my training program. (1 the least, 10 the highest)
Please write your top 2 nutrition related questions

WAIVER FORM

This form is an important legal document. It explains the risks you are assuming by beginning an exercise program. It is critical that you read and understand it completely. After you have done so, please print your name legibly and sign in the spaces provided at the bottom.
Waiver and Covenant Not to Sue

I have volunteered to participate in a program of physical exercise under the direction of Bridget Jackson, ATC/LAT, MHA which will include, but may not be limited to, weight and/or resistance training, cardiovascular conditioning and/or kickboxing exercise. In consideration Bridget Jackson, ATC/LAT, MHA ’s agreement to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless Bridget Jackson, ATC/LAT, MHA , and her respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from.
Assumption of Risk

I recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure, fainting, disorders in heartbeat, heart attack, and in rare instances, death.

I understand that as a result of my participation in an exercise program, I could suffer an injury or physical disorder that could result in my becoming partially of totally disabled and incapable of performing any gainful employment or having a normal quality of life.

I recognize that an examination by a physician should be obtained by all participants prior to involvement in any exercise program.

If I have chosen not to obtain a physician’s permission prior to beginning this exercise program with Bridget Jackson, ATC/LAT, MHA, I hereby agree that I am doing so at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate.

I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary.
Date *
Name *

First Name Last Name
Signature

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Thank you for taking the time to fill out this application so that we can better survey. We are looking forward to YOUR RESULTS!

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Please take a moment and fill out the information below!

COVID-19 Awareness Waiver

Client/Trainer Responsibility Agreement

Training Application/Questionnaire

Thank you for taking the time to fill out this application so that we can better survey. We are looking forward to YOUR RESULTS!