Fill and Sign the Sports Physical Form 497331759

Informed Consent Form for Physical Fitness Program Client Information: ( Please Print or Type) Name: ________________________________________ Phone: ___________ Mailing Address: _______________________________________________ _______________________________________________ Email Address: __________________________ Date of Birth: ___________________ Age: ______________ Gender: ______________ Name of Emergency Contact: ________________________________________ Phone Number of Emergency Contact: __________________________ General Statement of Program Objectives and Procedures: I ___________________ (name of client ) understand that this physical fitness program includes exercises to build the cardiorespiratory system (heart and lungs), the musculoskeletal system (muscle endurance and 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 aerobic activities (treadmill, walking, running, bicycle riding, rowing machine exercises, group aerobic activity, swimming and other aerobic activities), callisthenic exercises, and weight lifting to improve muscular strength and endurance and flexibility exercises to improve joint range of motion. Description of Potential Risks: I _________________ (name of client ) understand that the reaction of the heart, lung, and blood vessel system to exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or 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 and agree that the personal trainer shall not be liable for any damages arising from personal injuries sustained by me while and during the personal training program. I also understand and agree that I will be using the exercising equipment of ______________________ (personal trainer or owner of studio) during the personal training program at my own risk. I assume full responsibility for any injuries or damages which may occur during the training. Description of Potential Benefits: I understand that a program of regular exercise for the heart, lungs, muscles and joints, may have many benefits associated with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function, and decrease in heart disease. I covenant and represent that I have had a recent physical checkup and have my personal physician's permission to engage in aerobic and/or anaerobic conditioning. For and in consideration of being allowed to receive personal fitness training from __________________ (Name of Trainer) , and the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned _____________________ (Name of Client) agrees to the above Training Program Policies and Descriptions and I do hereby further agree to the following: 1. It is hereby agreed that I, __________________ (Name of Client) , do fully comprehend and assume all risks involved in participating in this Personal Training Program. I have been advised by ___________________ (Name of Trainer) to consult my physician prior to my participation in said Program to insure that I am physically able to engage in strenuous physical activity. 2. Being fully cognizant, and assuming all risks involved in the Personal Training Program offered by _________________ (Name of Trainer) , I do hereby remise, release, quitclaim, and forever discharge __________________________________ (Name of Trainer and/Owner of Studio) , his employees or agents, administrators, successors and assigns, of and from any and all manner of actions, suits, debts, accounts, damages, judgments, executions, claims, or demands whatsoever in law or equity, or otherwise, against _________________________________ (Name of Trainer and/Owner of Studio) , his employees or agents, administrators, successors and assigns, which I, my heirs, executors, or administrators hereafter can, shall or may have, for, upon or by reason of any injury that I may sustain or incur while participating in the Personal Training Program of _________________ (Name of Trainer) , or while engaging in physical conditioning exercises. 3. In consideration of being allowed to participate in said Personal Training Program , I do hereby assume all risks of my involvement and do covenant and agree not to bring legal action for damages should I sustain any injury, and do further release ___________________ (Name of Trainer) , his employees or agents, administrators, successors and assigns from all acts of active or passive negligence on the part of _____________________ (Name of Trainer) , his employees or agents, administrators, successors and assigns. 4. I also agree to INDEMNIFY AND HOLD release __________________________ (Name of Trainer and/Owner of Studio) , his employees or agents, administrators, successors and assigns harmless from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including attorney’s fees brought as a result of my involvement in said Personal Training Program and to reimburse them for any such expenses incurred. Witness my signature this ________________ (date) . ____________________________ (Printed Name of Client) ____________________________ (Signature of Client) ____________________________ (Printed Name of Witness) ____________________________ (Signature of Witness)