Client Inquiry

Name*

First NameLast Name
Instagram and/or Facebook name?*
Age
Date of Birth

MonthDayYear
Date
Gender*

MaleFemale
Email*
example@example.com
Phone Number*

Area CodePhone Number
Emergency Contact Person

First NameLast Name
Phone Number of Emergency Person

Area CodePhone Number
Weight (lbs)
What type of fitness are you interested in?
Do you have the following conditions?

AnemiaArthritisAsthmaCardiovascular problemsDiabetes MellitusHypertensionGlaucomaBone problemsRespiratory issuesMigraineOther
Are you pregnant (Female only)?

YesNo
What are your goals in this program?*

Weight lossGain musclesBe physically fitSport performanceImprove overall health
Goals - please be specific
Any physical limitations?
All times above may not be available: What days & times works best for you? (in-person only, if virtual don’t pick times) All class are 55 mins and videos are on website for viewing www.FitnessVibes757.com*

(6AM) Monday, Wednesday, Friday & Saturday 9am(6PM) Monday, Wednesday, Friday & Saturday 9am(7pm) Tues Thurs & Sat 9am(8pm) Tues Thurs & Sat 9am, with LadrinaI would like to request private 1 on 1 TrainingI would like to request Virtual TrainingOther
What is the biggest challenge that can keep you away from your fitness goals?
Start date requested?

MonthDayYear
Date
Please upload 3 "BEFORE" pictures (example above) If you don’t have fitness wear, send me some for reference in what you have. Pictures are mandatory, this helps both of us guide you through your journey (any issues please dm or text 757-375-3436*

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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 using physical activity with Fitness Vibes 757.

Having such knowledge, I hereby release Fitness Vibes 757, 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/agreed fitness program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in Fitness Vibes 757 exercise programs.

*Please sign in agreement to the above liability waiver*
Client Signature- Pictures are required, if you want to send immediately, send some regular pics that shows your body type from your Instagram Or Facebook. There are no refunds for payments made once starting the program.

Clear
Date Signed

MonthDayYear
Date
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