Fitness Assessment and Waiver

Next Level Athletic Performance

Fitness Assessment and Waiver
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Birth Date

MonthDayYear
Gender
Age
Height
Weight
Sport
Position
Name of School
Instagram Handle
What are your fitness goals?
How much do you want to lose? (weight loss program only)
What do you need to improve in your Performance?
Are you currently exercising?
Ever been on an exercise/nutrition program?
If you answered yes please explain.
Scheduling
How many days a week would you like to train?
What days? If unsure leave blank.
What Time? If unsure leave blank.

:HourMinutesAM/PM Option
How did you hear about us?
Medical Restrictions/ Allergies
Do you have any current injuries, preexisting conditions or allergies? (please list below)
Nutritional Supplements
Are you currently taking any nutritional supplements?
What are you taking?
How often and How much?
Physical Activity Questionnaire and Waiver
HAS YOUR DOCTOR EVER TOLD YOU HAVE HEART TROUBLE?
DO YOU FREQUENTLY HAVE PAINS IN YOUR HEART OR CHEST?
DO YOU OFTEN FEEL FAINT OR HAVE SPELLS OF DIZZINESS?
HAS A DR. EVER SAID YOUR BLOOD PRESSURE WAS TOO HIGH?
HAS YOUR DR. EVER TOLD YOU THAT YOU HAVE A JOINT OR BONE PROBLEM THAT CAN BE AGGRAVATED BY EXERCISE?
DO YOU HAVE BACK OR NECK PROBLEMS?
ARE YOU OVER AGE 65 AND NOT ACCUSTOMED TO PHYSICAL EXERCISE?
IF YOU ANSWERED: YES TO ONE OR MORE QUESTIONS: PLEASE CONSULT YOUR DOCTOR BEFORE INCREASING YOUR ACTIVITY LEVEL!
PLEASE READ IMPORTANT INFORMATION ABOUT TRAINING SESSIONS.

1. Clients MUST provide Next Level Athletic Performance 24-hour notice of cancellation, in order to reschedule a training sessions.

2. Please call or text your trainer if you’re going to miss a training session.

3. Training sessions DO NOT carry over to the next set of sessions.

4. Training sessions CAN NOT be transferred between clients.

5. NO REFUNDS will be given for training packages.
Personal/Performance Training Waiver

I, the undersigned, hereby authorize Jerry Jones, his staff, and all independently contracted trainers to act on my behalf in their best judgment in the event of an emergency requiring medical attention. I acknowledge and agree to waive and release Jerry Jones, the staff of Next Level Athletic Performance Group, LLC, and all independently contracted trainers located at 935 175th Street Homewood, Il 60430 or 80 w. 79th Ave Merrillville IN, 46410, as well as any other facilities used for training, from any and all liability for injuries and illnesses sustained during training sessions.

I confirm that I have no known physical impairments that would affect my ability to participate in this training. I understand that any medical expenses resulting from illness or injury, whether in an emergency or non-emergency situation, are solely my responsibility or the responsibility of my parents or legal guardian.
Photograph/Image Consent

I hereby grant permission to Next Level Athletic Performance (NLAP) and its representatives to photograph, video, and otherwise capture my image. I understand that these images and recordings may be used on all of Next Level's social media platforms.

Additionally, I grant Next Level Athletic Performance and its representatives the right to reproduce, use, exhibit, display, broadcast, and distribute these images and recordings across any media, whether currently known or developed in the future, for the purposes of promoting, publicizing, or explaining Next Level Athletic Performance's training, as well as for educational or research purposes.

I acknowledge that all photographs, video images, and voice recordings captured are the property of Next Level Athletic Performance.
Emergency Contact
Name

First NameLast Name
Phone Number

Area CodePhone Number
Client or parent signature

*IF CLIENT IS UNDER 18 YEARS OF AGE, PARENT MUST SIGN FOR CLIENT.
Signature
Should be Empty:

Next Level Athletic Performance

Scheduling

Medical Restrictions/ Allergies

Nutritional Supplements

Physical Activity Questionnaire and Waiver

Emergency Contact

Client or parent signature