Personal Coaching Payment and Waiver

Personal Coaching Payment and Waiver Form
I offer several options for personal coaching. An initial consultation is required for all new clients. This session allows more time to complete a comprhensive assessment of technique, along with sport-specific strength, flexibility and stability, as well as individualized planning for ongoing training and support.

Initial Consultation - $149
Individual Follow-Up Session - $119
Block of 4 Sessions - $399
Block of 8 Session - $699
Health Info and Waiver
Athlete's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AGREEMENT AND RELEASE OF LIABILITY

1. In consideration of participating in a training session with Craig Strimel and in addition to the payment of any fee or charge, I do hereby waiver, release and forever discharge Craig Strimel, and all other participants in a given program, from any and all responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf.

2. I understand and am aware that strength, flexibility, and aerobic exercise, including the use of equipment, are a potentially hazardous activity. I also understand that these activities involve a risk of injury and even death and that I am voluntarily participating in these activities and using equipment with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.

3. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in any of the activities recommended by Craig Strimel. I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physicians as to physical activity, exercise, and equipment use. I acknowledge that I have either had a physical examination and have been given any physician’s permission to participate, or that I have decided to
participate in activity and/or use of equipment without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment in my activities.
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Electronic Signature. If under the age of 18, parent's electronic signature confirming they have read and accept the above Agreement and Release of Liability:*
Type you full name
HEALTH HISTORY QUESTIONNAIRE
Sex*

MaleFemalePrefer not to indicate
Height*
Weight*
Physician's Name*
Physician's Phone*
In case of emergency contact:*
Emergency Contact Phone*
This form is not a substitute for a thorough physical examination, assessment and diagnosis by your physician. It is designed to identify people for whom physical activity might be inappropriate at this time. You are strongly recommended to undergo a medical examination before beginning any exercise
programs.

HAVE YOU EVER BEEN TREATED FOR, OR DIAGNOSED WITH THE FOLLOWING:

Heart Attack/ Disease/ High Cholesterol

Diabetes Mellitus (Req. Insulin Therapy)

High Blood Pressure/ Low Blood Pressure

Liver Disease

Coronary Bypass/Heart Surgery

Angina Pectoris

Embolism

High Blood Pressure (Req. Medication)

Pacemaker

Stroke

Cancer

Pacemaker

Major Surgery

Chest pain

Aneurysm

Epilepsy or Seizures

Metabolic Syndrome

Chronic Asthma/Lung Disease

Surgical Weight Reduction Procedure

Kidney Disorder

Arthritis/ Bone Conditions

Low blood sugar
Please list any of the above conditions you have experienced
Please check all that apply to you:

Male over 45 years old or female over 55 years oldDo you smoke? If no, have you quit within the previous six months?Have you had major surgery or been hospitalized within the past year?Are you currently pregnant? If yes, when are you due?Other
Are you presently under medical care, supervision, under restrictions from your physician for any other health related issues?If yes, please explain:
Is there any other medical condition not mentioned that may limit your physical activity:
Please list all prescription and/or over the counter medications you currently take:
Please list all vitamins, minerals, and nutritional supplements you currently take:
I understand the nature of the Health History Questionnaire and I am aware that any strenuous physical activity involves risk. Accordingly, I release,
discharge, absolve, and hold harmless Craig Strimel and all associated from any and all liability arising out of any accident, injury, or loss sustained by me as
a result of activities prescribed or directed by Craig Strimel.
I declare, to the best of my knowledge, that all my answers are true, correct, and complete.
Name*

First NameLast Name
Electronic Signature. If under the age of 18, parent electronic signature confirming you have read and accept the above statement*
Type your full name
Payment

You can pay for sessions in person with cash or check, via our Venmo business account, or here with a credit card. If you paying with cash, check or Venmo, select your option here, but do not select anything in the credit card payment window below, and submit this form without payment.
Select your option*

Initial Consultation - $149Individual Follow-Up Session - $119Block of 4 Sessions - $399Block of 8 Session - $699
If paying via Venmo, click the image, scan the QR code, or search for @southjerseytfc (South Jersey Track & Field Club is a DBA of Strimel Consulting LLC.)

If paying with credit card, select your option and enter information below.

Initial Personal Coaching Consultation $149.00

90 minute session including:A comprehensive assessment of technique, along with stability, flexibility and strength. Discussion of specific needs and/or goals.

Individual Training Session (after initial consultation)$119.00

Individually scheduled training session for technique check-in, on-going support at random intervals.

Training Session Block - 4 Sessions$399.00

Four training sessions scheduled in advance.

Training Session Block - 8 Sessions$699.00

Eight training sessions scheduled in advance.

Total $0.00

Credit Card

Strimel Consulting LLC, DBA South Jersey Track & Field Club

www.southjerseytfc.com

Craig Strimel:

craig@southjerseytfc.com

856-240-0508
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Personal Coaching Payment and Waiver Form

Health Info and Waiver

Payment

Credit Card