New Member Health Questionnaire

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

List any medical concerns.

List any restrictions or limitations that instructors need to know about.

Please answer each question: check YES or NO.

	Yes	No
Are you experiencing any pain or discomfort?
Do you feel fain in your chest when you do physical activity?
Has your doctor ever said that you have a condition and that you should only do physical activity recommended by a doctor?
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?
Is there anything that you want to discuss with us before your session?

What are your goals for training?

How often do you exercise per week?

Please select the best times you can exercise.

Please select the best days you can exercise.

What is your rate for your nutrition?

0 is Poor, 5 is Excellent

ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNIFICATION AGREEMENTI, the undersigned Participant (or if Participant is under 18 years of age, the parent or legal guardian of the minor Participant), hereby acknowledge and agree to the following:

1. Acknowledgment of Risks: I understand that the activities described above, including but not limited to Stand-Up Paddleboard (SUP) Yoga, on-water activities (such as paddling, balancing on unstable surfaces, and exposure to water), general yoga (involving poses, stretches, and physical exertion), fitness classes (including cardio, strength training, and group exercises), and outdoor functional training (such as running, climbing, bodyweight exercises, and environmental challenges), involve inherent risks and dangers. These risks may include, but are not limited to:

• Physical injury from falls, slips, trips, collisions, or strains (e.g., muscle pulls, sprains, fractures, or dislocations).

• Drowning, near-drowning, or water-related hazards (e.g., currents, waves, marine life, or submerged objects during SUP and on-water activities).

• Overexertion, heat exhaustion, sunburn, dehydration, or exposure to weather elements (e.g., sun, rain, wind, insects, or uneven terrain in outdoor settings).

• Risks from equipment failure, instructor error, or other participants’ actions.

• Aggravation of pre-existing medical conditions, including but not limited to heart issues, joint problems, pregnancy, or respiratory conditions.

• In the context of SUP Yoga and on-water activities, additional risks include capsizing, wind gusts, tidal changes, and interactions with boats or wildlife in Florida waters, particularly in Brevard County areas like the Indian River Lagoon or Atlantic coastal zones.

• For yoga and fitness: Risks from improper form, inversion poses, or intense physical demands leading to injury.

• For outdoor functional training: Risks from natural obstacles, variable terrain, or group dynamics.
I affirm that I am in good physical condition and have no medical conditions that would prevent safe participation. I agree to inform the instructor of any limitations or injuries before starting. I voluntarily assume all such risks, known and unknown, even if arising from the negligence of the Releasees (defined below) or otherwise.

2. Release of Liability: In consideration of being permitted to participate in the activities, I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Five by Five Intl, LLC dba SoulVival Wellness, its owners, officers, directors, employees, agents, instructors, volunteers, affiliates, successors, and assigns (collectively, the “Releasees”), from any and all liability, claims, demands, actions, or causes of action whatsoever arising out of or related to any loss, damage, injury, or death that may be sustained by me, or my property, whether caused by the negligence of the Releasees or otherwise, while participating in or traveling to/from the activities. This release includes, without limitation, claims for personal injury, property damage, wrongful death, or emotional distress.

3. Indemnification: I agree to INDEMNIFY AND HOLD HARMLESS the Releasees from any and all liabilities, claims, demands, actions, or causes of action, including costs and attorneys’ fees, arising from my participation, including those resulting from my negligence or that of a third party.

4. Medical Authorization: I authorize Releasees to obtain or provide medical care for me in case of emergency, including transportation to a medical facility. I release Releasees from liability for such care. I confirm I have adequate health insurance and agree to pay for any medical expenses incurred.

5. Media Release: I consent to the use of my photograph, video, or likeness for promotional purposes by Releasees without compensation. I waive any right to inspect or approve such uses. If I do not consent to photos or videos or likeness being used, I must email yoga@soulvivalwellness. com this request.

6. Governing Law and Severability: This Agreement shall be governed by the laws of the State of Florida. If any provision is found invalid, the remainder shall remain in full force. This is the entire agreement.

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. I AM AT LEAST 18 YEARS OLD (OR MY PARENT/GUARDIAN SIGNS BELOW). NO ORAL REPRESENTATIONS HAVE BEEN MADE TO MODIFY THIS AGREEMENT

All cancellations must be received at least 4 hrs before your session in order to avoid being charged. Clients who do not cancel with 4 hrs notice will be charged 1 credit for the cancellation unless approved by instructor. SoulVival Wellness understands that emergencies happen. We provide members with one complimentary short-notice cancellation a month. You will not be charged for your first cancellation with less than 4 hr notice. Subsequent short notice cancellations will be charged for the session. The free short-notice cancellation only applies if SoulVival Wellness or your instructor is notified prior to the session start time. No show are not eligible for the free cancellation.

I authorize Wellness Wellness to bill my credit card for purchased sessions, packages and memberships according to outlined schedule of billing. Although all accounts are no-contract, proper notification must be completed to cancel account.

Client Signature

Date

New Member Health Questionnaire

Release and Acknowledgement

Cancellation & Expiration of Sessions Policy

Billing Policy