Fill and Sign the Personal Trainer Agreement Form

Contract with Personal Trainer including Release, Waiver, Assumption of Risk and Indemnity Agreement Name of Client: _______________________________________________ Address of Client: _______________________________________________________ (street address, city, state, zip code) Age: _____ Date of Birth: _______________ Referred By: _______________________ Mailing Address (if different than above): __________________________________________ Primary Phone Number: ________________ Alternate Phone Number: _______________ Primary Email: ___________________________________ Name and Address of Employer: ______________________________________________ _____________________________________________ Occupation: ________________________ Emergency contact: ______________________________ PAR-Q 1 / Risk Factors - (If you answer yes to any of the following questions 1-9, please talk with your doctor about becoming physically active). 1. Has your doctor ever said you have a heart condition and should only do activity recommended by a doctor? Yes_____ No_____ 2. Do you feel pain in your chest when you do physical activity? Yes_____ No_____ 3. In the past month, have you had chest pain when you were not doing physical activity? Yes_____ No_____ 4. Do you lose your balance because of dizziness or do you ever lose consciousness? Yes_____ No_____ 5. Do you suffer from shortness of breath at mild exertion or have difficulty breathing? Yes_____ No_____ 6. Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes_____ No_____ 7. Is your doctor currently prescribing drugs for your blood pressure or heart condition? Yes_____ No_____ 1 Physical Activity Readiness Questionnaire 8. Do you know of any other reason why you should not do physical activity? Yes_____ No_____ 9. Are you above 40 years of age and not currently physically active? Yes_____ No_____ 10. Has your doctor ever said you have high blood pressure (140/90 mm Hg or above)? Yes_____ No_____ 11. Have you ever taken any medication to lower your blood pressure? Yes_____ No_____ 12. Has your doctor ever said you have high blood cholesterol (200 Total or above)? Yes_____ No_____ 13. Do you have diabetes or high blood sugar? Yes_____ No_____ 14. Do you currently smoke or have you quit in the last 6 months? Yes_____ No_____ Terms of Agreement I, ___________________ (Name of Client) , of _____________________________________ (street address, city, state, zip code) , hereinafter referred to as Client , on ______________ (date) enter into this Agreement by and between ____________________ (Name of Personal Trainer) , a limited liability company organized and existing under the laws of the state of ________________, with its principal office located at ___________________________ ________________ (street address, city, state, zip code) , referred to herein as Trainer . Whereas, Trainer, as a limited liability company, conducting personal training services through its employees; and Whereas, Client has requested to hire Trainer to act as Client’s personal trainer during personal training sessions at Trainer’s studio located at _______________________________ _____________ (street address, city, state, zip code) , or in Client’s home, office or other location (hereinafter Studio, Home, Office or Location, or referred to collectively as Location , with said training sessions to be provided pursuant to the fee schedule set forth below; and Whereas, Trainer agrees to provide said Training sessions to Client subject to the terms and conditions of this Agreement; Now, therefore, for and in consideration of the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: ASSUMPTION OF THE RISK: I am aware that activities associated with receiving personal training instruction from Trainer including, but not limited to activities involving aerobic exercise, stretching exercise, running and weight lifting, as well as additional strenuous exercise and/or exertion of strength, and other sustained physical activities which place stress on the cardiovascular and muscular systems (collectively referred to herein as Training ), are and can be hazardous activities that include certain risks and dangers, including but not limited to, catastrophic injuries including paralysis, other serious injury, and death. I VOLUNTARILY ASSUME ALL RISKS INVOLVED, INCLUDING RISKS FROM TRAINING IN ANY WAY WITH THE USE OF EQUIPMENT PROVIDED BY THE TRAINER OR USE OF EQUIPMENT I PROVIDE, AND WHETHER THE TRAINING OCCURS AT THE STUDIO, MY HOME, OFFICE OR ANY OTHER LOCATION. WAIVER AND RELEASE: In consideration of my participation in the training provided by Trainer I, for myself, my heirs, executors, administrators or assigns, do hereby release, waive, discharge, release, and covenant not to sue Trainer and/or its members, managers, officers, directors, agents, employees, and affiliated entities (hereinafter referred to as Releasees ) from liability and from any and all claims, including the negligence of Trainer, resulting in personal injury, accident or illnesses, including death, and property loss arising from participation in the training and use of the facilities, premises or equipment wherever located and by whomever provided. I acknowledge and agree that Trainer has not inspected the equipment at the Location or the suitability of the area for Training. INDEMNIFICATION AND HOLD HARMLESS: Client agrees to indemnify and hold the Releasees harmless against loss (including reasonable attorneys’ fees) from any and all claims of negligence, demands, rights, or causes of actions of any kind or nature that may hereafter at any time be made or brought by Client or on Client’s behalf for any known or unknown, foreseen and unforeseen bodily or personal injuries, damages to property and consequences thereof which may be sustained by Client as a direct or indirect result of participating in the aforementioned activities and use of the equipment of the Trainer or provided by a third party or me. INDEPENDENT CONTRACTOR: Contractor is an independent contractor and is not an employee, servant, partner or joint venturer of Client. Client shall determine the services to be provided by Contractor , but Contractor shall determine the legal means by which it accomplishes the services in accordance with this Agreement Client is not responsible for withholding, and shall not withhold or deduct from the commissions FICA or taxes of any kind, unless such withholding becomes legally required. Contractor is not entitled to receive workers compensation, unemployment compensation, medical insurance, life insurance, paid vacations, paid holidays, pension, profit sharing, or Social Security on account of its services to Client. _________ Initialed by Client SEVERABILITY AND JURISDICTION: The invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision. This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of ____________. ARBITRATION : Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. PHYSICIAN APPROVAL: I have represented to Trainer that I have either:  Been given a physician’s permission to participate in the Training, or  Voluntary participate in the Training and all risks related to the Training without the approval of my physician(s).  I represent that I am not aware of any medical or physical condition that would prevent me from participating in the Training or from using equipment or facilities which pose a serious health risk to me. I further acknowledge that Trainer has relied on my statements as being accurate and complete, as a condition to entering into this Agreement.  I understand and agree that I am not obligated to participate in any Training that I do not wish to participate in. I will inform Trainer immediately if I do not wish to participate in any specific Training. NAME AND LIKENESS RELEASE: I understand that Trainer, may photograph or video me prior to, during the delivery of Training, or at the completion of Training and I agree to allow Trainer to use photographs and videos of me, as well as, name and likeness for promotional purposes. RESCHEDULING / MISSED SESSIONS: I understand that some months may have more sessions than normal and some may have less (due to holidays / missed sessions) and that the same monthly investment applies regardless of sessions trained during month. I acknowledge that missed sessions are forfeited unless rescheduled with at least twenty-four (24) hours notice prior to delivery of training. Rescheduled sessions may be made up during same training month (In addition to normal program) unless agreed upon extended client absence of 2+ sessions, then missed sessions are added to end of program. Client has read, and fully agrees to the terms of this Agreement and understands and agrees that by signing this Agreement (which contains a waiver, release and assumption of risks) Client has given up considerable future legal rights. Client has signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to him/her. Client certifies and warrants that he/she is ________ (i.e., age of majority such as 18) years of age or older and mentally competent to enter into this Agreement. PAYMENTS: First payment will be debited on the day of first training session (after free session) with future payments approximately on the same day each month (every 30 days) thereafter until completion / termination of training program. All programs are an initial 6, 12 or 18 months and will renew automatically after the full term of the program on a month to month basis with same monthly rate, unless Client gives notice of program termination by phone only at 800-719-3608 at least 14 days from the next debit date. If for any reason the 12 or 18 month programs are cancelled before completion, the amount of the difference between the cost of 6 month or 12 month and the current contract cost per month for every month trained is due immediately. EFT Payment Authorization: Client hereby authorizes Trainer or its assigns to make periodic charges or withdrawals (“EFT Authorization”) from my account as listed below for the payment of any and all fees, expenses or any other monies due Trainer. Client waives the right to receive prior notice for charges of withdrawals made with respect to any uncollected payments or portions of the balance due described below and the corresponding service charge. (Please specify if different billing name or address from listed on front). Payment Type (Visa / MasterCard / Discover / AMEX / Checking / Savings): ___________________________________________________ (For Credit Card) - Credit Card #: _____________________________________________ Expiration Date: __________________________ (For Checking) - Bank Name: ____________________ ABA Routing Number: _______________ Account Number: ___________________ Platinum Training - 3 weekly sessions – 6 / 12 / 18 month program = $447 or $407 or $367 monthly investment (Plus Tax) Gold Training - 2 weekly sessions – 6 / 12 / 18 month program = $317 or $287 or $257 monthly investment (Plus Tax) Silver Training - 1 weekly sessions – 6 / 12 / 18 month program = $177 or $157 or $137 monthly investment (Plus Tax) Initial Program Length: _______ (Months) -- Monthly Program Fees: ___________ (Plus Tax) –- First Auto Debit: ________________ (Date) ACKNOWLEDGEMENT OF UNDERSTANDING : I have read the Assumption of Risk, Waiver of Liability, provisions in this Agreement and I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the Agreement freely and voluntarily and intend, by my signature that this document be a complete and unconditional release of liability to the greatest extent allowed by law. I further certify that I have fully read and understand the terms of this agreement and will comply with the contents herein. Witness our signatures this the _____ day of _________________, 20 ____. (Name of LLC) ______________________________________ ______________________________ (Signature of Member or Officer) (Signature of Client) ______________________________________ ______________________________ (Printed Name of Member or Officer) (Printed Name of Client) Initial Assessment (For Trainer Use Only) Pictures: _______ Start Weight / Sizes: ________________________Goal Weight / Sizes: ___________________ Girth - Arm (R)_______ Waist_______ Hips_______ Thigh (R)_______ Calf (R)_______ Skinfold - Tricep_______ Abdomen_______ Suprailiac_______ Thigh_______ Notes / Success Indicators: __________________________________________________________________________________ ___________________ - __________________________________________________________________________________ _