Bosslady Fit waiver & Enrollment

Welcome sheet - Client information
Birth Date*

MonthDayYear
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Clients informations - Health questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

Rows	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Any recent surgery/ or cosmetic procedures in past 12 months ? And are you clear to return ?

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials*
Liability waiver
I am aware of the risks and hazards connected with participating in the facilities group or private exercise sessions I understand injuries can happen to myself & my property or even death if I'm not aware of any illness that can cause me death .I voluntarily assume full responsibility for any risk or loss property damage .
I understand the facility does video recording for promotion of the facility I will let them know if I don't want to be recorded on a basic or on any specific day .

I also understand that all payments made to enroll or come in as a drop in are non refundable .
Initials*
Signature*
Full name*

First NameLast Name
Date

JourMoisAnnéeHourMinuteAM/PM Option
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