STEP 1- Older Not Over!

STEP 1- Older Not Over!

Your Results Await! Unleash your Potential! We can be fit over 50! Answer the questions below & submit the form as step 1. Choose from 1:1 or Small Group Training (in person), Zoom-based, Virtual (app based). Don't worry, all come with a professionally designed plan, with YOU in mind and the support you need to succeed! Time to thrive!
Full Name*

First NameLast Name
Gender

Female
Date of Birth*

MonthDayYear
Age*
years
Phone Number*

Area CodePhone Number
Email*
How do you prefer to be contacted?
What do you do for a living?*
How did you hear about me?*
Whats the activity level at your job?*

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Weight (optional)
If unknown that's okay
Height
ft
What’s your current fitness routine, if any?*
Do you follow a regular work schedule, do you work days, afternoon or nights?
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems list the condition(s).*
If you are on any medications, please list them.
If you have any injuries, please list them.
Has your doctor given permission for all types of exercise: cardio, resistance, stretching? *
Please list any past joint surgeries if any including their dates. *
Has a doctor or physical therapist (or other medical professional)recommended you avoid any particular exercises or movements? If so, what?*
Are you experiencing any stresses or motivational problems?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo
if yes please list:
Are you a current cigarette smoker?*

YesNo
Please rate your readiness for change.*

12345678910
What are your goals?*

Improved HealthTone UpIncreased StrengthIncreased Muscle MassFat LossImproved Overall FitnessBalance, Mobility, LongevityOther
What are your specific goals with your training (if you have specific goals not already mentioned)?
Why? (Intention driving goal/event?)
Any history of eating disorders?

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

Have you trained with a personal trainer before?*

YesNo
Are you looking for:
At what times during the day would you prefer to train?*

MorningMid-DayAfternoonEvening
I have in person and zoom availability MWF AM, TH early pm, Sat AM… list your preferred days to meet
How many days per week would you like to train together in person, virtually, combo *
If we move forward, is it okay to post photos and videos to social media of training and/or progress photos?

YesNoOnly TrainingOnly Progress
Are you okay with Progress Photos (taken personally)?

YesOnly for trainer to seeOnly for personal trackingNo
What are your expectations on me as your Personal Trainer?
1.)

CANCELLATION POLICY

No-shows = no refund

Cancellations with less than 24 hours notice = 90% refund

Cancellations with 24+ hours notice = full refund or credit

If you're sick or showing signs of illness, please stay home. I'd rather reschedule than have you push through and risk spreading it to others (or making yourself worse).

I deeply value your consistency. but I also believe in listening to your body and being respectful of the group. Thank you for understanding and helping maintain a healthy, energized space for everyone.

. 2.) LATE ARRIVALS Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I verify this information to be true and accurate. I acknowledge this is an application to request fitness training from Amy Cicoria, LLC and understand training does not replace the advice of my doctor, and that I will only participate in programs recommended for me by my doctor. I do not hold Amy Cicoria, LLC, Amy H.Cicoria DBA or Fusion Fitness Studio Classes and Training DBA or Dansville Dance Academy/ Stacey Corriea responsible for any loss or injury related to training or content.*

Yes
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