Health History Questionnaire Logo
  • Health History Questionnaire

    Thank you for taking the time to complete this questionnaire.  Your responses ensure that we tailor the program to your unique fitness goals, and fully understand any limitations or concerns you may have.
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  • Contact Information

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  • Person to Contact in Case of Emergency

    This person must be available during class times.
  • 2Unstoppable is a 501c3 non-profit organization. Copyright © 2024 2Unstoppable ®- All rights reserved

  • Doctor Information

    A physician release to exercise is required prior to starting this program.
  • Medications

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  • Physical Activity

  • 2Unstoppable is a 501c3 non-profit organization. Copyright © 2024 2Unstoppable ®- All rights reserved

  • Cancer History

  • Please help us learn a little about your cancer treatments

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  • 2Unstoppable is a 501c3 non-profit organization. Copyright © 2024 2Unstoppable ®- All rights reserved

  • Medical History

  • 2Unstoppable is a 501c3 non-profit organization. Copyright © 2024 2Unstoppable ®- All rights reserved

  • Additional Information

  • Financial Assistance

    We're committed to making our programs accessible to everyone.
  • 2Unstoppable is a 501c3 non-profit organization. Copyright © 2024 2Unstoppable ®- All rights reserved

  • AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

  • I agree that I have enrolled in personal training sessions and/or group training sessions, offered by 2Unstoppable (a non-profit organization) and Instructors that are Certified Cancer Exercise Specialists (the “Program”). I recognize that the Program may involve strenuous physical activity, including but not limited to, muscle strengthening, stretching and cardiovascular conditioning and training and other various fitness activities. I hereby affirm that I am in good physical health and do not suffer from any known disability or condition which would prevent or limit my participation in these sessions. I will not start this Program if my physician or health care provider advises against it. If I experience faintness, dizziness, pain or shortness of breath at any time while exercising I should stop immediately and call my doctor or 911. If I do have a condition or other health issue that could be made worse by a change in physical activity, I have received medical clearance to participate in these sessions.

     

    In addition, I am fully aware of the risks and hazards associated with participating in a physical fitness program, such as the Program, including but not limited to, physical injury or even death. I understand that we will be conducting sessions online and my 2Unstoppable Instructor will not be physically present with me and cannot see my form in 360˚ view due to the limitations of online training. I understand that my home environment or where I choose to do online training is not under the control of the instructor. I hereby elect to voluntarily participate in online personal training or online group training knowing that the associated risks may be hazardous to me and/or my property.  I herby assume all risk of injury or harm related to my participation in the Program and release 2Unstoppable from all liability for injury, illness, death, property damage or property loss resulting from my participation in the Program.

     

    Further, I hereby expressly release and forever discharge and hold harmless 2Unstoppable and its successors and assigns from any and all liability, claims and demands of any kind or nature, either in law or in equity, which arise or may hereafter arise from my participation in 2Unstoppable’s Program, to the extent allowed by applicable law. I agree that this release discharges 2Unstoppable from any liability or claim that I may have against 2Unstoppable with respect to any bodily injury, personal injury, illness, death, or property damage that may result from my participation in 2Unstoppable’s Program, whether caused by the negligence of 2Unstoppable or its officers, director, employees, volunteers, third parties, or otherwise. I also understand that 2Unstoppable does not assume any responsibility for or obligation to provide financial assistance or other assistance, including, but not limited to medical, health, or disability insurance in the event of injury or illness. I AGREE TO HOLD HARMLESS, INDEMNIFY AND DEFEND 2UNSTOPPABLE AND ITS AGENTS, EMPLOYEES, SUCCESSORS OR ASSIGNS AGAINST AN AND ALL CLAIMS, DEMANDS, CAUSES OF ACTION, DAMAGES, JUDGMENTS, ORDERS, COSTS OR EXPENSES, INCLUDING ATTORNEY’S FEES, WHICH MAY BE INITIATED AGAINST ANY OF THE FOREGOING BY ANY PERSON ARISING FROM OR CONNECTED WITH ACTIVITIES CONDUCTED RELATED TO MY PARTICIPATION IN THE PROGRAM.

     

    It is also my expressed intent that this waiver and release shall also be deemed a full release, waiver, discharge, and covenant not to sue insofar as my aforementioned family members, heirs, assigns, and personal representatives are concerned. I hereby further agree that this waiver and release shall be governed and interpreted in accordance with the laws of the State of Virginia and/or the state in which I reside. I agree that in the event that any clause or provision of this release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this release which shall continue to be enforceable. In electronically signing or agreeing to this waiver and release, I hereby affirm that I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

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  • 2Unstoppable is a 501c3 non-profit organization. Copyright © 2024 2Unstoppable ®- All rights reserved

  • Attendance/Participation Policy:

  • To make the most of the program, please:

    Notify your instructor in advance: If you're unable to make it to class, please email your instructor with at least 24-hour notice.

    Let us know if you're running late: We understand that sometimes unexpected situations may occur, but if you think you'll be more than 15 minutes late, please give your instructor a heads-up.

    Be present and engaged: Committing to be present and engaged in every class is a powerful step towards achieving your full potential in the program.

    Keep your camera on: So we can best support you, we require that your Zoom video always be on during class.

    Reach out for help if needed: If you find that you cannot attend multiple classes or are falling behind, we're here to touch base with you and discuss how we can help you get back on track.

    Investing in Your Strength: Program Costs

    6-Week Program= $100

    Refunds and Rescheduling

    If unforeseen circumstances prevent your participation after payment, please get in touch with ilana@2Unstoppable.org.

    The 2Unstoppable Team

  • 2Unstoppable is a 501c3 non-profit organization. Copyright © 2024 2Unstoppable ®- All rights reserved

  • Payment Form

  • If you prefer to mail your check please send to:

    2Unstoppable
    PO Box 2019
    Fairfax VA 22031

    Thank you!

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