New Client Physical Readiness and Liability Form

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Home Phone*

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Profession:
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Areas of interest

Gym MembershipPersonal TrainingSpa Services

Please read the following questions carefully and answer them honestly. All information is kept confidential*

	Yes	No
Has a doctor ever said you have heart trouble?
Do you frequently suffer from pains in your chest?
Do you often feel faint or have spells of severe dizziness?
Has a doctor ever told you that you have joint or bone problems that have been aggravated by or may worsen with exercise?
Do you have any medical conditions?
Is there any other reason not mentioned as to why you
Should not engage in physical activity on a regular basis?

If you have answered yes to any of the above, please explain below:
Do you smoke?*

YesNo
If Yes, how many packs per day?*
Rate your level of stress on a scale of 1-10 (10 being the highest)*
What are your fitness goals?*
Additional Comments
Is member/client a minor under 18 years of age?*

YesNo
Guardian Name*

First NameLast Name
Guardian Signature*

Clear
VOLUNTARY ASSUMPTION OF RISK

I understand that any exercise, personal training, and lifestyle program involves the risk of injury, despite reasonable precaution and without anyone being at fault. I know that people can and do become injured while doing aerobic exercise or while working with weights and other fitness equipment. Injuries that can occur include but are not limited to dizziness, fainting, nausea, muscle cramping, muscular-skeletal injury, broken bones, sprains, and strains. In rare instances, people may experience a heart attack, stroke, or sudden death. I understand that there are risks associated with weight loss or eating certain foods. Risks can include (but are not limited to) an allergic reaction, nausea, vomiting, or diarrhea. There may be long-term effects with certain foods or sugar substitutes, such as Nutra-Sweet, that may not be known. I understand that The Spa at Yellow Creek cannot list all possible risks of injury that can happen with exercise or weight loss. I understand that my doctor is the best person for me to talk about all risks. I acknowledge that The Spa at Yellow Creek has recommended and encouraged me to have a physical examination with my physician and to speak with my doctors about any risks associated with my participation in programs offered by The Spa at Yellow Creek. With reasonable laypeople's understanding of the risks and benefits of exercise and weight loss, I knowingly and voluntarily assume full responsibility for all risks of injury and death. If I am pregnant, I also knowingly and voluntarily assume full responsibility for all risks of injury or death of my unborn child.
VOLUNTARY RELEASE OF LIABILITY

In consideration for my being allowed to participate in the exercise, personal training and lifestyle coaching programs, as well as my use of the facilities and equipment at The Spa at Yellow Creek, I (on my behalf of anyone claiming through me, including heirs, administrators, executors) knowingly and voluntarily forever waive, release, discharge and promise not to sue or file a claim, now of in the future against The Spa at Yellow Creek (including its employees, officers, directors, shareholders, agents, successors and assigns) because of any injury, damage or death, which resulted directly or indirectly from my membership and/or use of its facilities & equipment, and/or my participating in any of its programs.
VOLUNTARY SIGNATURE

I read this form or had it read to me. I understand what it says. I understand that by voluntarily signing it, I attest to, (1) I am at least 18 years old and capable of making binding decisions; (2) all information I furnished in my health history is accurate, complete and true; (3) I agree to the enforceability of all provisions of the Voluntary Assumption of Risk, Waiver, and Release of Liability.
I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment today.
MEMBER NAME*
MEMBER SIGNATURE*

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Date:*

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Date
The form is an enforceable legal document that will be interpreted and governed by the Ohio law, regardless of any state's conflict or laws legislations. Exclusive jurisdiction and venue are vested in Summit County Common Pleas Court, Summit County, Ohio.
Should be Empty:

VOLUNTARY ASSUMPTION OF RISK

VOLUNTARY RELEASE OF LIABILITY

VOLUNTARY SIGNATURE