Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

What is the activity level of your job(s)? *

Low (seated or standing)

Moderate (walking)

High (very active/heavy labor)

Are you interested in or comfortable exercising outside weather permitting?

Yes

No

Select the days you can exercise indoors *

Wednesday

Thursday

Friday

Saturday

Select days you can exercise outdoors (ignore for winter)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Select the times you can exercise *

Early Morning 9-10

Morning 10-12

Early Afternoon 12-2

Late Afternoon 2-4

Evening

What goal(s) best fit with your goal? *

Strength

Flexibility

Reduce stress

Minimize pain

Training for an event

Endurance

Other

Testimonial *

Are you open to sharing a testimonial of your experience at the end of your program?

Yes

Maybe

No

I, hereby acknowledge that the information I've given above is complete and accurate to the best of my knowledge. I understand all the risks and I accept full responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential. *

Yes

No

Date *

MM

DD

YYYY

Client Signature *

First Name

Last Name