Service Sign Up Sheet

What service are you interested in?*

Personal TrainingEntry Level Boxing ClassBoth
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Is this consultation for a minor?*

YesNo
Gender

MaleFemale
Date of Birth

MonthDayYear
Age*
Height*
Feet/Inches
Weight*
( If your not sure or don't feel comfortable sharing just yet, no problem type in N/A)
What do you do for a living?
(Type N/A If not applicable)
If You Are ONLY Interested in Entry Level Boxing Classes, Only Answer Mandatory Questions From This Point Forward. Type or Select in N/A for Mandatory Questions that may not apply to you, or if you do not know the answer to the question.

Thank You.
Whats the activity level at your job?

None(seated only)Moderate (light activity such as walking)High (heavy labor, very active)N/A
Do you follow a regular working schedule, do you work days, afternoon or nights?
(Type N/A If not applicable)
How often do you travel?

RarelyA few times a yearA few times a monthWeeklyN/A
Please list the physical activities that you participate in outside of the gym and outside of work:
(Type N/A If not applicable)
If you have any diagnosed health problems list the condition(s).*
(Type N/A If not applicable)
If you are on any medications, please list them.*
(Type N/A If not applicable)
What additional therapies are being undertaken for the given health problem(s)?*
(Type N/A If not applicable)
If you have any injuries, please list them.*
(Type N/A If not applicable)
What additional therapies are being undertaken for the given injury?
(Type N/A If not applicable)
Are you experiencing any stresses or motivational problems?

YesNoI have my moments
Has anyone of your immediate family developed heart disease before the age of 60?

YesNoNot sure
Do any diseases run in your family?

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

YesNo
Please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Please rate your readiness for change.

12345678910
What following goals does best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?
Why?

TIme-line for achieving your goal.

	3 months	6 months	12 months
NOW

How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
Are you currently excersising regulary (at least 2x per week)?

YesNo
Have you trained with a personal trainer before?

YesNo
What kind of training did you do? Did you enjoy it?
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
How often do you want to do Personal Training a week?
Please Choose
What are your expectations on me as your Personal Trainer?
1.) CANCELLATIONS

Cancellations should be made at least 2 hours in advance of a scheduled session. Sessions cancelled less than 2 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 1 hour in length. There is a 15 minute grace period before session is canceled. 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 AGREE TO THE ABOVE TERMS & CONDITIONS!

YesNo
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If You Are ONLY Interested in Entry Level Boxing Classes, Only Answer Mandatory Questions From This Point Forward. Type or Select in N/A for Mandatory Questions that may not apply to you, or if you do not know the answer to the question.