DPT Fit Group Training Intake

Dance Performance Training

Cross-Training Made Easy: Improve Your Dance Performance with Our Proven Method
New Client Information

See the "*" for required information. All other questions are optional. Thank you for filling this in; we can't wait to see your improvements with our programs!
Name of Client*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of Parent or Legal Guardian (if client is under 18 years old)

First NameLast Name
Email of Patient/Client*
example@example.com
Email of Parent/Legal Guardian
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Client Phone Number

Area CodePhone Number
Parent/Guardian Phone Number

Area CodePhone Number
Name and City of Dance Studio or Company
Occupation
What's your primary style of dance/performing art?*
What other styles of performing arts do you participate in?
How did you first hear about us or our services?*
Want to share more about how you heard about us?
Share as much info as you'd like on who or where you learned about us here.
Would you say you are more focused on pain/injury recovery or skill/performance improvement?*
We know both are important, but which lead you to want to work with us more?

Dance Performance Training

Cross-Training Made Easy: Improve Your Dance Performance with Our Proven Method
Participant Release and Acknowledgement of Agreement
I, {nameOf4}, wish to participate in the exercise and training program offered by DPT Fit LLC dba Dance Performance Training. I understand there are inherent risks in participating in a program of strenuous exercise; consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. If I choose not to see a physician prior to beginning a fitness program, I do so strictly at my own risk. I further agree that DPT Fit LLC dba Dance Performance Training shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, outdoors or in any fitness facility), and I expressly release and discharge DPT Fit LLC dba Dance Performance Training from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only and injury caused by an intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.
Check below that I have read, agree with, and understand the above statements.*

I agree
I understand that DPT Fit LLC dba Dance Performance Training will make every reasonable effort to preserve the privacy of the information contained in this Client Intake Form. I further agree that DPT Fit LLC dba Dance Performance Training shall not be liable or responsible to me for any inadvertent disclosure of the information contained in the Client Intake Form and I expressly release and discharge DPT Fit LLC dba Dance Performance Training from all claims, actions, judgment and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any damage which may occur in connection with disclosure of private information contained in the Client Intake Form. This release shall be binding upon my heirs, executors, administrators and assigns.
Check below that I have read, agree with, and understand the above statements.*

I agree
I certify that the answers to the questions outlined on the PAR-Q from are true and complete to the best of my knowledge. I acknowledge that medical clearance is requested if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform DPT Fit LLC dba Dance Performance Training of any condition or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.
Check below that I have read, agree with, and understand the above statements.*

I agree
I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participations at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform DPT Fit LLC dba Dance Performance Training.
Check below that I have read, agree with, and understand the above statements.*

I agree
I understand that the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.
Check below that I have read, agree with, and understand the above statements.*

I agree
I certify that I have read and consent to the following documents and that these documents are readily available for me should I need to review them.
Terms of Use
Privacy Policy
Check below that I have read, agree with, and understand the above statements.*

I agree

Waiver for Minors
In consideration of using the services of DPT Fit LLC dba Dance Performance Training, on behalf of myself ({nameOf5}), my heirs, personal representatives, or assigns, we (parent and minor client) do hereby release, waive, discharge, and covenant not to sue DPT Fit dba Dance Performance Training, its owner, officers, employees, volunteers, and agents, from liability from any and all claims arising from the ordinary negligence of DPT Fit dba Dance Performance Training or any of the aforementioned parties.

This agreement applies to personal injury (including death) from accidents or illnesses arising directly or indirectly from participation in activities directed, suggested, or planned by DPT Fit dba Dance Performance Training including, but not limited to, organized activities, camps, classes, instruction, observation, related activities in a non-supervised setting, and use of facilities, premises, or equipment

Indemnification and Hold Harmless: We (parent and minor client) also agree to hold harmless and indemnify DPT Fit dba Dance Performance Training, its owner, officers, employees, volunteers, agents, and insurance carriers from all claims (whether initiated by us or by a third party) and to reimburse them for any expenses incurred as a result of my involvement with DPT Fit dba Dance Performance Training. We (parent and minor client) further agree to pay all expenses, including court costs and attorneys’ fees, incurred by DPT Fit and the aforementioned parties in investigating and defending a claim or suit resulting from my participation in any DPT Fit dba Dance Performance Training fitness and wellness activities.

Acknowledgment of Understanding: We (parent and minor client) have read this waiver of liability and indemnification agreement and fully understand its terms. We (parent and minor client) understand that we are giving up substantial rights, including our right to sue. We (parent and minor client) acknowledge that we are signing the agreement freely and voluntarily, and intend our e-signatures to be a complete and unconditional release of all liability for injury resulting from ordinary negligence to the greatest extent allowed by law.
Initials

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Check here to signify I have truthfully answered these questions about my medical history, condition and consent to the below text to be used as an electronic representation of my signature.*

I agree
Signature of Client (or guardian if client under 18 years old)*

Clear
Name of the Above Signer*

First NameLast Name
Should be Empty:

Dance Performance Training

New Client Information

Dance Performance Training

New Client Goals & Lifestyle

Dance Performance Training

PAR-Q (Physical Activity Readiness Questionnaire)

Dance Performance Training

Participant Release and Acknowledgement of Agreement