Fitness Intake Form

Name

First NameLast Name

Birth Date

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Email

example@example.com

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please state if you have current/previous health diseases/issues.

Please state whether you take any medication.

How many months will you do exercise?

Please select the reasons you eat (besides hunger).

What are your goals for training?

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 dancing. I am informed that my information in this form will be kept confidential.

Coach Pj has informed me that I am the only responsible party both for all the injuries during the dance fitness 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

Fitness Intake Form

Release and Acknowledgement