• Health & Wellness

    Personal Information
  • Birth Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Step 2

    Medical / Health
  • What do you consider your diet to be best described as:
  • Please select the reasons you eat (besides hunger).
  • Step 3

    Goals
  • Which are you looking to do
  • Please select the best times you can exercise.
  • What are your goals for training?
  • Please rate your motivational level to do what it takes for reach your goal.
  • Please rate your readiness for change.
  • Step 4

    POLICY
  • 🚨 UPDATED CLIENT POLICY 🚨

    Effective August 1, 2026

    Please review the updated policies below carefully. By booking and/or confirming your sessions, you acknowledge and agree to the following terms.

    PAYMENT POLICY

    Payment must be made in full at least 48 hours prior to your first scheduled workout session.

    All payments are non-refundable.

    ⸻

    SESSION CANCELLATIONS

    Once your training days and times have been confirmed, your schedule is locked in and cannot be changed.

    Cancellations are non-refundable and cannot be rescheduled. Please make sure the day and time you select are suitable for your schedule before confirming your sessions.

    ⸻

    LATE ARRIVALS

    Please arrive on time for every scheduled session.

    Arriving late may result in your session being reduced in duration.

    Arriving more than 15 minutes late will result in the session being automatically canceled.

    A canceled session due to late arrival will not be rescheduled or refunded.

    ⸻

    NO CALL / NO SHOW (NC/NS)

    Failure to call or show up for a scheduled session is considered a No Call/No Show and is a failure to communicate.

    1st NC/NS: Warning

    2nd NC/NS: $20 NC/NS fee

    3rd NC/NS: $20 NC/NS fee and termination of training services

    Please be mindful that your scheduled time is reserved specifically for you. Failure to communicate and not showing up is a waste of reserved training time.

    ⸻

    SQUEEZE-IN / MAKE-UP SESSIONS

    If you cancel a scheduled session and would like to make up the session in order to complete your 12-session package, a $65 squeeze-in fee will apply.

    If you need to change a scheduled training day or time after your schedule has been confirmed and locked in, a $65 schedule-change fee will apply.

    The applicable fee must be paid before the new session or schedule change is confirmed.

    Thank you for respecting these policies and my time as your trainer. These updates are in place to ensure consistency, fairness, and accountability for all clients.


    Buttaphly Fitness 🦋

  • Release, Acknowledgement & Waiver

  • I the client, 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.

  • WAIVER

    It is my desire to utilize the premises, facilities, and equipment owned by Victoria Fitness located at 444 Broadway, Menands, NY 12204 (hereafter called "Owner").

    I acknowledge that there could be a risk of personal injury in the use of the premises, facilities, classes, and equipment.
    In consideration of the Owner allowing the undersigned user to be on and to utilize said premises, facilities, classes and equipment, I agree to assume the risk of personal injury. I agree to hold harmless the Owner and the employees of Victoria Fitness, as a business and individually, from any and all liability claims, damages, losses, or cause of action, which may be incurred by the user while he/she is on said premises, or while using said equipment or taking any classes. I agree to hold harmless the Owner and the employees of Victoria Fitness for anything that may arise, including, but not limited to, any negligence, any loss arising from theft, or any other reason whatsoever.
    In addition, (if the user is a minor) I hereby grant permission for the user to be on the said premises, and to utilize the facilities and equipment thereon.
    Because physical exercise can be strenuous and subject to risk of serious injury, we urge you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You agree that by participating in physical exercise or training activities, you do so entirely at your own risk. Any recommendation for changes in diet including the use of food supplements, weight reduction and/or body building enhancement products are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes. You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death. We are also not responsible for any loss of your personal property. You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a release of liability. You expressly agree to release and discharge the trainer or instructor from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer or instructor for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from. By purchase of ticket, I acknowledge that I understand its content and that this release cannot be modified orally.

  • Date
     - -
  • Should be Empty: