MEKENIFICENT FITNESS INTAKE

MEKENIFICENT FITNESS INTAKE

Location: 63 Jan Jonker Road, Klein Windhoek
Client Name*

First NameLast Name
Birth Date

MonthDayYear
Date
Address*

Street Address

Suburb

Town Region

Zip code
Phone Number*

Area CodePhone Number
Email
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Please state if you have current/previous health diseases/issues.*
Please state whether you take any medication.*

Health & Lifestyle

	Yes	No
Do you smoke?
Have you had any surgery since one year?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Have you done sports professionally before?
Do you feel pain while doing sports/exercise?

At which frequency you eat at night?

	0	1	2	3	4	5

0 is Never, 5 is Always

At which frequency you eat breakfast?

	0	1	2	3	4	5

0 is Never, 5 is Always

Please select the reasons you eat (besides hunger).

StressDepressionBoredomHappinessHabitAnnoyanceOther

What is your rate for your nutrition?

	0	1	2	3	4	5

0 is Poor, 5 is Excellent

How often can you exercise per week?
How many months will you sign up with us?
Please select which program you are signing up for. Memberships are paid monthly into our accounts.

Personal training at center(N$1,500.00)Personal training at home (N$3,000.00)Bootcamp (N$350.00)Bootcamp (3 months special N$750.00)Kapunda must fall challenge (N$450.00)Kapunda must fall challenge 3 months plus free Fitness & Health book (N$1,350.00)Normal membership (N$350.00)Kids fitness (N$250.00)Saturday abs class (N$100.00 plus free smoothie)
Our training section is open throughout the day. Below are times when a trainer is available. Please select the best times you can exercise with our trainers.

5:00am6:00am7:00am8:00am4:30pm5:30pm
What are your goals for training?

Development of musclesReducing the stressLosing Kapunda fatIncreasing the motivationTraining for an event/specific sportsOther
Please select the best days you can exercise.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
PAYMENT POLICY:

Seeing as we do not bind you to a contract, it is your responsibility to ensure that each month you send the proof of payment to our office info@mekenificent.co or 0814417900 / 0813343382. You can Pay 2 cell 0814417900 OR into the account: MEKENIFICENT WELLNESS CC FNB Acc #: 62245822483 Branch: MAERUA MALL Branch code: 282273 Ref: your name or number
Release and Acknowledgement
I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential.

The fitness center has informed me that I am the only responsible party both for all the injuries during the fitness program and incorrect information. I release and discharge the fitness center trainers, administration and workers from any disclosure of my personal information in this Fitness Client Intake Form.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the fitness center authorities immediately.
Date

MonthDayYear
Date
Client Signature

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MEKENIFICENT FITNESS INTAKE

PAYMENT POLICY:

Release and Acknowledgement