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					                                              REGISTRATION FORM
                                                           CLIENT INFORMATION
Today’ Date:                                      Birth Date:                                     Age:


Last Name:                                                                First Name:


Street Address:


City:                                                       State:                                       Zip Code:


Home Phone #:                                                             Cell Phone #:


Occupation:                                                               Work Phone #:


E-mail Address:


Choose how you heard of Fit-4-Life, Inc.:             Yellow Pages              Ad/Mailer              Online

        Friend (Specify)                Family (Specify)             Other (Specify)

Physician:                                                                Physician Phone #:


Number of children:                                                       Children Ages:




                                                      IN CASE OF EMERGENCY
Name of local spouse, friend, or relative:                                                     Relationship:


Home Phone #:                                                             Work Phone #:




                                    UPDATED CLIENT INFORMATION (Office Use Only)
Address:                                                                                                        Date Changed:


Phone #s:                                                                                                       Date Changed:

   Home #:                                         Work #:                                          Cell #:

E-mail:                                                                                                         Date Changed:


Miscellaneous:                                                                                                  Date Changed:


Miscellaneous:                                                                                                  Date Changed:




Fit-4-Life, Inc.                                                                                            (856)596-4966
Page 1 of 7                                                                                              www.FitLifeInc.com
                                                               Fitness Goals
                            CHOOSE APPROPRIATE RESPONSE(S), SKIP IF NOT DESIRED
 1. Lose weight or body fat?            1-10 lb loss                  10-20 lb loss                 20-30 lb loss                  +30 lb loss
         Other (Specify)

 2. Toning or firming?           Abs              Hips                Buttocks               Arms                   Thighs                Calves
         Other (Specify)

 3. Improve performance for a specific sport(s)?               Golf           Tennis              Football           Basketball           Soccer           Baseball
         Crew       Field Hockey          Lacrosse            Other (Specify)

 4. What season is your sport?           Fall        Winter             Spring             Summer

 5. Decrease pain or discomfort?            Low Back           Neck              Shoulder             Knee             Foot/Ankle           Elbow            Hip
        Wrists       Overall         Other (Specify)

  6. Improve flexibility?        Low Back          Neck              Shoulder              Knee               Foot/Ankle          Elbow            Hip
        Wrists       Overall         Other (Specify)

  7. Increase strength?          Low Back          Neck           Shoulder                 Knee            Foot/Ankle             Elbow        Hip
        Wrists       Overall         Trunk/Core            Upper Body                Lower Body                 Other (Specify)

 8. Any of the following?          Improve endurance             Increase energy level                     Reduce stress            Other (Specify)

 9. Days available to exercise per week?            1-2          3-4             +5

10. Days available to exercise at Fit-4-Life per week?                 1         2           3            4

11. Why do you want to train at Fit-4-Life?              Continual basis for motivation and safety                     Learn program to do at home or gym
        Update and re-evaluate routine periodically throughout year                    Other (Specify)

12. Do you belong to a health club or gym?               No           Yes (Specify)

13. Do you exercise at home?           No          Yes

14. Exercise equipment you have at home?                 Treadmill           Exercise Bike                Stepper          Free Weights              Stability Ball
       Multi-Station Home Gym          BOSU Balance Trainer                  Fitness Tubing/Bands                   Dumbbells (Specify)
       Exercise Tapes/DVDs (Specify)                      Other (Specify)

15. Nutrition concerns?          Food selection           Portion Control              Meal Frequency                 Eating Out           Caloric Intake
       Sports Nutrition         Other (Specify)

16. Would you be interested in personal chef services?                 Yes            No           I would like to find out more

17. When would you like to train?        AM (Specify times)                       PM (Specify times)
       Flexible (Preferences)

18. Where would you like to train?           Fit-4-Life Studio             In-home               Office           Other (Specify)

19. Do you have a personal trainer you would like to work with?                       No           Yes (Specify)
   All Fit-4-Life trainers are equally qualified, alternating trainers improves appointment availability and exercise variety




Fit-4-Life, Inc.                                                                                                                (856)596-4966
Page 2 of 7                                                                                                                  www.FitLifeInc.com
                                                      Medical Profile

    Check and give date of occurrence(s) if you ever had or have any of the following with a brief description
       Anemia                                                      Hernia

       Ankle Pain/Injury                                           High Blood Pressure

       Arthritis                                                   High Cholesterol

       Asthma            Inhaler   Yes     No                      Hypoglycemic

       Back Pain/Injury                                            Knee Pain/Injury

       Cancer                                                      Low Blood Pressure

       Chest Pain                                                  Lung Disease

       Chronic Illness                                             Thyroid Condition             Hypo      Hyper

       Congenital Heart Disease                                    Ulcers

       Diabetes              Type I      Type II                   Muscle Sprains

       Dizziness/Lack of Balance                                   Broken Bones

       Eating Disorder                                             Multiple Sclerosis

       Epilepsy                                                    Lupus

       Headaches(Chronic)                                          Fibermylagia

       Heart Murmur                                                Neck Pain/Injury

       Heart Attack                                                Stroke

       Heart Palpitations/Arrhythmias                              Obesity

       Smoking within last 2 years                                 Shoulder Joint Pain

       Pregnant or within last 3 months                            Advised not to exercise

       Surgery in last 12 months                                   Other Joint Pain
    PLEASE LIST OR EXPLAIN ANY OF THE ABOVE MEDICAL CONDITIONS OR OTHERS NOT LISTED




   Sports Injuries (Specify)

   Physical Therapy within past 3 years (Specify)

   Medications and/or supplements (List)



                                          FAMILY HISTORY (CHECK ALL THAT APPLY)
                               Cancer               Diabetes   Heart Attack/Stroke           Kidney Disease        Obesity

Parents

Siblings

Children

                                   UPDATED MEDICAL INFORMATION (OFFICE USE ONLY)




Fit-4-Life, Inc.                                                                                (856)596-4966
Page 3 of 7                                                                                  www.FitLifeInc.com
                                                          Exercise History

                                                    CHECK APPROPRIATE RESPONSE
  1. Are you or have you ever been involved in any form of exercise?                 Yes           No     If no, skip to question #13


 2. Are you currently exercising?           No        Yes      If yes, skip to question #5


 3. How long has it been since you have been exercising regularly?                     Weeks                Months             Years


 4. What was the biggest reason why you most recently stopped exercising?                      No Time          Low Motivation           No Results

       Exercise Soreness         Joint Pain (Specify)                   Other


  5. How long have/had you been exercising?               1-5 months            6-12 months             1-3 years         +4 years


 6. How often do/did you exercise?            1-2 times/week            3-4 times/week             5 or more times/week


 7. How long do/did you exercise each workout?                 1-15 minutes          15-30 minutes            30-60 minutes            +60 minutes


 8. Where do/did you exercise?           Home             Health Club/Gym            Other (Specify)


9. Type of exercises performed?             Walk        Run          Stepper          Biking            Free Weights         Strength Machines

       Pilates      Yoga        Stretching           Exercise Videos            Exercise Classes           Stability Ball/ BOSU balance trainer

       Resistive Tubing/Bands          Balance          Other (Specify)


10. If strength training, which exercises performed?              Abs/Core           Squats          Chest Press           Lat Pulldowns       Bicep Curls

         Tricep Pushdown         Leg Press           Leg Extension/Curl            Other (Specify)


11. How many set per exercise?              1-3        +3      How many repetitions?             1-6          7-12         13-20        +20


12. If stretching, which target areas?            Low Back         Hamstrings           Neck            Hip Flexors        Groin/Inner thigh

       Chest/Pectorals        Calves          Shoulders          Other (Specify)


13. Do you have any exercise preferences or dislikes?              No           Yes (Specify)


14. Any negative feelings or bad experiences with exercise?                No        Yes (Specify)


15. Favorite physical/recreational sports, activities or hobbies?                  Performance level?            Novice         Amateur           Elite


16. How often do you perform your sport, activity, or hobby?                Weekly         Monthly        Seasonal (Which seasons)

       Other


17. Have you worked with a personal trainer?              No         Yes        If yes, answer the following question


18. Was the experience?          Positive          Negative      Explain?


19. Do you expect to buy new exercise equipment in the near future?                   No         Yes (Specify)




Fit-4-Life, Inc.                                                                                                         (856)596-4966
Page 4 of 7                                                                                                           www.FitLifeInc.com
                                   Policies & Objectives

                               STATEMENT OF PROGRAM OBJECTIVES

      I understand that I am entering into a physical fitness program which includes exercises to build the
cardiovascular system (heart and lungs), the musculoskeletal system (muscle endurance, strength, and
flexibility), and to improve body composition (decrease of body fat in individuals needing to lose fat, with an
increase in weight of muscle and bone). Exercise may include weight lifting and aerobic type activities. The
results obtained by an individual will depend on many factors, including such individuals’ body composition,
genetics, and efforts. To facilitate my use of the program, I agree to the following rules/regulations.

                                               CLIENT POLICIES

1. Trainings must be purchased by check, cash, or credit card (Visa, Mastercard) before a client schedules
    appointments. Clients can purchase as few as one or as many as twenty trainings at one time. Scheduling
    future appointments is the responsibility of the client.

2. Clients cannot begin training until after a medical clearance (if appropriate) is fully completed by the client’s
    medical practitioner for safety purposes.

3. Appointments are scheduled for up to 55 minutes. Those who come late can use the time remaining on their
    scheduled time.

4. Cardiovascular/aerobic training (treadmills, steppers, bikes, etc.) can be performed before or after a client’s
    scheduled appointment time. To allow for a proper warm-up, come in a minimum of 5 minutes before your
    scheduled appointment.

5. A client is fully charged for missed appointments unless prior notice is given.

6. One training will be charged to all clients who cancel appointments within a 24 hour period of
    their scheduled appointment time. Sorry no exceptions (weather permitting). If you are not
    feeling well, cancel immediately for the week to avoid any cancellation fees. Appointments can
    always be rescheduled if you are feeling better and availability exists. Policy still applies for
    Monday appointments cancel over the weekend 24 hours in advance.

7. Fit-4-Life is not responsible for lost or stolen valuables in the facility. Please remember to lock up all personal
     items.

8. Refer a new client and receive one free training if they purchase 10 or more trainings during a single purchase.

9. All the above mentioned policies are also applicable to Friends-in-Fitness. A partner whom does not attend an
    appointment is still financially responsible for that training.



 I do understand and agree to follow the terms of this agreement for as long as I am a
Fit-4-Life, Inc. client. This agreement does not obligate me to purchase any Fit-4-Life services.

Date:                                  Signature:



Fit-4-Life, Inc.                                                                         (856)596-4966
Page 5 of 7                                                                           www.FitLifeInc.com
                            Informed Consent Waiver

                                             POTENTIAL RISKS


     I understand that exercise contains certain risks, which I will discuss with my personal physician. If my
personal physician believes certain exercise would be inappropriate for me, I will advise my trainer and/or Fit-4-
Lie, Inc. and such exercise will be eliminated from the program. I know there is a possibility of certain abnormal
changes occurring during or following exercise, which may include abnormalities of blood pressure, heart rate,
ineffective functioning of the heart or in rare instances heart attacks. Use of the weight lifting equipment, and
engaging in heavy body calisthenics may lead to musculoskeletal strains, pain and injury if adequate warm-up,
gradual progression, and safety procedures are not followed. I understand that my trainer and/or Fit-4-Life, Inc.
is not responsible for any injuries.



                                           INFORMED CONSENT




    I desire to voluntarily engage in an exercise program developed by my trainer and/or Fit-4-Life, Inc. in order
to improve my exercise tolerance, my cardiovascular function, my flexibility, and my strength.

     I agree to pay the fees for such a program.

    Before I enter this exercise program, I will have a basic evaluation made by my personal physician. This
evaluation will include a medical history and measurements of heart rate, blood pressure, strength, and flexibility.

    The information that is obtained will be treated as privileged and confidential and will not be released or
revealed to any person other than my physician without my expressed written consent. The information
obtained, however may be used for a statistical or scientific purpose with my right or privacy retained.

     I hereby acknowledge that my participation in these training sessions organized by my trainer and/or Fit-4-
Life, Inc. will necessarily require physical and mental dedication and exertion. I hereby assume the risk of any
injury or damage to my person or property resulting from in connection with the use by me of the equipment
provided by my trainer and/or Fit-4-Life, Inc. and agree to defend, indemnify and hold my trainer and/or Fit-4-
Life, Inc. harmless of and from any claim, demand, action or cause or action for injury, damage or loss of person
to property asserted by or occurring in favor of me.


Signature of Participant:                                                           Date:


Witness:                                                                            Date:



Fit-4-Life, Inc.                                                                       (856)596-4966
Page 6 of 7                                                                         www.FitLifeInc.com
Fit-4-Life, Inc.      (856)596-4966
Page 7 of 7        www.FitLifeInc.com

				
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