CH Muay Thai Fitness Client Registration Form

CLIENT DETAILS

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

E-mail*

PARENT/GUARDIAN DETAILS

Parent/Guardian Full Name

First NameLast Name

Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Phone Number

Parent/Guardian E-mail

example@example.com

Emergency Contact 1*

First NameLast Name

Emergency Contact 1 E-mail*

example@example.com

Emergency Contact 1 Phone Number*

Emergency Contact 2

First NameLast Name

Emergency Contact 2 E-mail

example@example.com

Emergency Contact 2 Phone Number

HEALTH QUESTIONNAIRE*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had any chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsened by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction

Initials*

MEDICAL HISTORY

Have you had any family history of chronic disease (heart disease, diabetes, etc.)?*

If yes, please list

Have you ever been diagnosed or treated for any chronic disease including asthma?*

If yes, please list

Are you currently taking any medication?*

If yes, please list

Any other conditions that we need to be aware of (i.e. Past or present injuries, etc)?*

If yes, please list

If you have answered YES to any of the above questions, you must obtain a medical clearance prior to carrying out a physical exercise program.

HEALTH RELATED BEHAVIOURS

Do you smoke?*

If yes, how many a day?

Do you drink alcohol regularly?*

If yes, how much per week?

How many times on average do you eat fast food per week?*

How many hours of sleep do you normally get per night?*

PSYCHOLOGICAL

Please rate the following. One star being negative to five stars being positive

I have a positive attitude towards things

My job stresses me out.

I am in the best shape of my life.

I would rate my current health.

I am serious about acheiving my goals

GOALS

Do you have any health related goals (i.e. Lower blood pressure, etc)?*

If yes, please list

Do you have specific goals related to body composition (i.e. weight loss, build biceps etc)?*

If yes, please list

Do you have any performance specific goals (i.e. Increase to 10km run, increase chest strength, etc.)?*

If yes, please list

Do you wish to achieve any of these goals in a specific time frame?*

If yes, please explain

LIABILITY WAIVER

Please read carefully before submitting this form.

To participate, all participants must read this statement before accepting.

The purpose of this disclaimer and notice is to make you conscious of the potential risks connected with activity in any combat exercise and events, physical fitness, or training program, and to help you make an informed decision as to whether you should participate in these types of activities/events.

Injuries of all types can occur when participating in exercise, physical fitness, events, and training programs, CH MUAY THAI advising the risks involved and fully assume the risk of any resulting injury short term and long term. Such injuries include but are not limited to:

· Bruising, cuts, and general soreness

· Muscle and tendon injuries

· Fractured or broken bones

· Concussions

· Heart attack

· Skin infections, rashes, or grazes

. Death

Appropriate gym/sports clothing and equipment must be worn as well as clean and appropriate footwear.

If you already have boxing/training gloves and advised equipment these must be worn to participate.

It is advised that all participants take out adequate personal injury insurance to ensure extra cover for injuries.

IMPORTANT – if the participant feels unwell in anyway whilst participating in the event they must stop immediately and only continue when they feel better to do so and/or seek medical advice.
The participant or parent/guardian of the participant must inform CH MUAY THAI of any pre or existing health condition or injury.

I agree, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, that I am voluntarily participating in physical activity with CH Muay Thai Fitness. I am aware of the risks in observing or participating in the activities offered and sponsored by CH Muay Thai fitness and I understand that all sports or fitness activities that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death.

Having such knowledge, I hereby release CH Muay Thai Fitness, their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program.

It is understood that CH Muay Thai fitness is responsible for any damage that would be resulting from a fault of CH Muay Thai fitness and its representatives.

Please tick box in agreement to the above liability waiver*

I Agree

24H CANCELLATION POLICY

All cancellations must be received at least 24h before your training session in order to avoid being charged. Clients who do not cancel with 24h notice will be charged 50% of a regular price session for the cancellation.

CH Muay Thai fitness understands that emergencies happen. We provide every client with one free short-notice cancellation. You will not be charged for your first cancellation with less than 24h notice. Subsequent short notice cancellations will be charged for the session. The free short-notice cancellation only applies if CH Muay Thai fitness, or your trainer is notified prior to the session start time. No shows are not eligible for the free cancellation.

Please tick box in agreement to the above 24h cancellation policy*

I Agree

PHOTO WAIVER RELEASE FORM

I hereby grant the releasee permission to use photographs in any of the following:

Release of Photographs in

Web-based publicationsPrint AdvertisementsOrganization Bulletin

I hereby affirm that such release to the releasee does not constitute any form of compensation, including royalties arising from the photographs, to my benefit. I understand and agree that photographs in the possession of the releasee shall become the property of the releasee. The use and publication of the photographs however, shall conform to my rights as a subject of said photographs. I hereby waive my right to inspect of approve the photographs by which my likeness appears. I hereby hold harmless, release, and forever discharge the Ch Muay Thai from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

Age of Consent

I am of legal ageI am a minor and represented by my parent/guardian

I declare true my age of consent, and in case I am under the age of such consenting age, I have obtained the required consent from my parents/guardians as evidenced by the signatures below:

Name of Person Subject of Photograph

Signature

Name of Parent/Guardian of Person Subject of Photograph

Signature of Parent/Guardian

Date SIgned

Date

Please read carefully before submitting this form.

To participate, all participants must read this statement before accepting.

I am the*

CH MUAY THAI reserve the right to use any photos/video taken on the premises for social media/marketing purposes.

In registering as a participant and in consideration of being permitted by CH MUAY THAI to participate in the classes. I voluntarily agree to assume all risks in and incidental to participation in combat related activities and events. Moreover, I release CH MUAY THAI, their instructors, coaches, agents, and all staff from all claims of injuries, damage, demands and actions whatsoever, whether such damage be known or unknown. This also includes solicitor’s fees in any other matter arising out of or resulting from or in connection with participation CH MUAY THAI.

For Parent/Guardian signing this form: I confirm that I have disclosed any relevant information to advise any health condition or injury on behalf of the minor I am responsible for.

Full Name*

First NameLast Name

Signature*

Date*

JourMoisAnnéeHourMinutesAM/PM Option

Client Information - Personal Details

CLIENT DETAILS

PARENT/GUARDIAN DETAILS

Client Information - Emergency Contact

Client Information - Health and Medical Details

MEDICAL HISTORY

HEALTH RELATED BEHAVIOURS

PSYCHOLOGICAL

Terms and Conditions

LIABILITY WAIVER

24H CANCELLATION POLICY

PHOTO WAIVER RELEASE FORM

Client Signature