PT by KG Presents: Maintain, Don't Gain Holiday Challenge

Name

First NameLast Name

Today's Date

Date

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Birthday

Date

Do you exercise regularly?

Rate your ability to perform cardio exercise:

Rate your experience with exercise:

BeginnerIntermediateAdvanced

1. Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension (high blood pressure), high cholesterol, or diabetes? (If YES, please explain.)

2. Do you feel pain in your chest when you perform physical activity?

YESNO

3. In the past month, have you had chest pain when you were not performing any physical activity?

YESNO

4. Do you lose your balance because of dizziness or do you ever lose consciousness?

YESNO

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

YESNO

6. Do you have any existing injuries or have had any surgeries in the last 3-6 months?

PT by KG Presents: Maintain, Don't Gain Holiday Challenge Liability Acknowledgement Form:

I, the participant, desire to participate in the Maintain, Don't Gain Holiday Challenge. I agree to take personal responsibility for any actions that are part of this challenge. I agree to assume full responsibility for any risks, injuries or damage, known or unknown, which I might incur as a result of participation in the challenge. In addition, I knowingly, voluntarily and expressly waive any claim I may have against Personal Training and Wellness by Katie for injury or damages that I may sustain as a result of participating in these activities. I understand that I should consult with a physician before I undertake any weight-loss program, exercise regimen, or lifestyle change. I will not, nor will anyone acting on my behalf, hold my Personal Training and Wellness by Katie, responsible for any injuries that might occur from my participation in this challenge.

*Before beginning any weight-loss program, exercise regimen or lifestyle change, individuals should consult with their personal physician to ensure that they are healthy enough to participate. Reasonable Alternative: If you think you might be unable to meet the requirements under this program (or if it is medically inadvisable for you to do so), you may still be able to have a personalized program created by Katie at an additional cost. Please contact Katie at katiegladney@gmail.com and she will work with you (or if you wish, your doctor) to find you an alternative.

I acknowledge that I have read and understood this Maintain, Don't Gain Holiday Challenge Liability Acknowledgement Form and that I am freely and voluntarily agreeing to it.

Please select one:

AGREEDON'T AGREE

PT by KG Presents: Maintain, Don't Gain Holiday Challenge

Please answer YES or NO to the following questions: