CD FIT Registration Forms

CD FIT FITNESS PROGRAM
CLASS LOCATION & TIME: *
DESIRED START DATE: *

Month Day Year
Date
HOW DID YOU HEAR ABOUT US: *
Referral, Groupon, FaceBook, Instagram, Commercial, Etc...
MEMBERSHIP or TRIAL TYPE (GROUPON VOUCHER NUMBER): *
(8 Digit Groupon Voucher Number Located Below the Bar Code, If Applicable)
NAME (Last, First, Middle Initial): *
Full Legal Name As Listed On Your ID
HOME ADDRESS: *
CITY: *
STATE: *
ZIP CODE: *
PHONE (H)
(W):
CELL/PAGER: *
EMAIL ADDRESS: *
example@example.com
DOB: *
AGE: *
WEIGHT: *
GENDER:
PHYSICIAN: *
PERSON TO NOTIFY IN CASE OF EMERGENCY: *
RELATIONSHIP: *
PHONE: *
Disclosure & Release

I, the Participant, agree to participate in a physical fitness program with a trainer or trainers of CD Fit (the “Program”).

I recognize that exercise is not without varying degrees of risk to the musculoskeletal and/or cardio-respiratory systems. I hereby certify that I know of no medical problems (except those of which I have informed the Program)
that would increase my risk of illness and injury as a result of participation in a physical fitness program with the Program.
I understand and have been informed that there exists the possibility of adverse changes during the exercise program. I have been informed that these changes could include abnormal blood pressure, fainting, disorders of heart rhythm, stroke, and very rare instances of heart attack or even death.
I agree to waive, release, remise, and discharge the Program and its agents, officers, principles, employees, and affiliates of any and all claims, demands, actions or damages of any kind resulting from participation in the Program. The undersigned further states he/she understands and assumes any and all risks with participation in the Program.
Participant' Signature *

Clear
Date *

Month Day Year
Date
CD FIT: HIGH PERFORMANCE TRAINING
NAME (Last, First, Middle Initial): *
Full Legal Name
Health History Questionnaire Health History Questionnaire
1. Please indicate YES or NO if you have had or currently have any of the following medical conditions and please explain, if yes:
Heart Disease *
Yes or No
Chest Pain *
Anemia *
Back Trouble *
Fainting Spells *
Joint Pain *
Diabetes *
Asthma *
Hernia *
Epilepsy *
Bleeding *
High Blood Pressure *
IF YES TO ANY OF THESE, PLEASE EXPLAIN: *
Type N/A if Not Applicable
Do you have or have you had any pain or tightness in the front or back of your chest? *
If yes, is it during exertion and/or with anxiety? *
Type N/A if Not Applicable
Have you ever been told you have an abnormal EKG? *
Do you ever have swelling of the feet and/or ankles following long periods of standing or intense physicalactivity? *
yes or no
Does your heart ever beat irregularly? *
yes or no
Has a physician ever said you have a heart murmur? *
yes or no
Do you get cramps in the back of your legs when you walk? *
yes or no
Have you noticed any circulatory problems in your feet or hands? *
yes or no
Do you have chronic lower back pain? *
yes or no
Do you have pain in your legs and/or feet? *
yes or no
Do you have joint pain, stiffness, swelling, or instability? *
yes or no
Do you have trouble walking/jogging or in using your hips, shoulders or knees? *
yes or no
2. Please describe any history of hospitalizations, operations and/or serious injuries: *
yes or no
3. Are you currently taking any medications (including non prescription)? Please provide specifics (i.e., what type, quantity, etc.) *
Yes or No? If yes, please provide specifics.
Participant's Signature *

Clear
Date

Month Day Year
Date
Should be Empty:

CD FIT FITNESS PROGRAM

CD FIT: HIGH PERFORMANCE TRAINING

Health History Questionnaire Health History Questionnaire