Essentrics Intake and Waiver Form
The information contained within this form will help Lynne Loiselle determine if you are able to participate in Essentrics classes or if medical clearance is required by your physician. Note: All information provided is kept confidential and only accessed by Lynne Loiselle at Because You Can Fitness.
Name
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First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (cell preferred)
*
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Would you like to be on my Essentrics mailing list?
*
Yes
No
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Essentrics and your Fitness Goals
What is your goal in practicing Essentrics (check all that apply)?
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Stress reduction
Improved flexibility
Increased strength
Overall sense of well-being
Weight management
Pain management
Injury prevention
Injury rehabilitation
Other
If "other", please describe.
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Health and Medical Questions
Are you currently experiencing any of the following medical conditions (check all that apply)?
High blood pressure
Low blood pressure
Respiratory problems (please explain in "other" box below)
Heart conditions (please explain in "other" box below)
Joint issues (ex: arthritis, joint replacement - please explain in "other" box below)
Osteoporosis
Muscle / tendon issues (please explain in "other" box below)
Dizziness / Fainting
Chronic pain or fatigue (please explain in "other" box below)
Vision and/or hearing loss
Other
If "other" please list or describe the medical conditions, physical limitations, surgeries and health concerns that you have.
Please list any medications that you are currently using and the reason for taking them.
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Release and Waiver - THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS. READ IT CAREFULLY.
Please consult your physician prior to starting an exercise or fitness program. To the best of your knowledge you are in good physical and mental condition and capable of participating in Essentrics® classes. You are not aware of any physical or mental illness or injury that prevents you from participating in Essentrics® classes. You, the client, are aware that there are risks associated with participating in Fitness activities and fitness including Essentrics®. Your participation is completely voluntary, and you freely accept and fully assume all responsibility for all risks, and all possibilities of personal injury, death, property damage or loss to yourself or any other person as a result of your participation in fitness activities including Essentrics® live classes or online with Lynne Loiselle. You and your heirs, next of kin, executors, administrators and assigns agree: (a) to waive all claims, known or unknown, that you have or may have in the future against Lynne Loiselle/Because You CanFitness and the hosting facility, including their owners, officers, directors, agents, employees, volunteers, business operators, independent contractors and site property owners or lessees (the “organization”); (b) that Lynne Loiselle/Because You Can Fitness is not liable or responsible for any damage to, loss or theft of your property; (c) to release and forever discharge Lynne Loiselle/Because You Can Fitness from all liability for any personal injury, death, property damage or loss resulting from your participation in fitness activities including Essentrics® classes due to any cause, including but not limited to negligence (failure to use such care as a reasonably prudent and careful person would use under similar circumstances), breach of any duty imposed by law, breach of contract or mistakein error of judgment of Lynne Loiselle/Because You Can Fitness; and (d) to be liable for and to hold harmless and indemnify Lynne Loiselle/Because You CanFitness from all actions, proceedings, claims, damages, costs demands, including court costs on a solicitor and own client basis, and liabilities of whatsoever nature or kind arising out of or in any way connected with your participation in fitness activities including Essentrics®.
Signature - I have read and agree with the Release and Waiver
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Date
*
-
Month
-
Day
Year
Date
Print
Submit
Submit
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