Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Medical Conditions (Current or Past)

Diabetes

Gallstones

Pregnant

Hiatal Hernia

Fatigue

Asthma

Digestive Disorders

Hypoglycemia

Kidney Stones

Joint Pain or Disorders

Eating Disorders

Cancer

Shortness of breath

Gout

Osteoporosis

Rheumatic Fever

Anemia

Fainting

Stomach Pain

Heartburn / Reflux

PLEASE READ AND FILL OUT THE FOLLOWING: *

I understand that I will be participating in a personal fitness training program that will include weight training, cardiovascular, stretching and balance oriented exercises. The session may also include boxing, kick boxing, and / or other exercises as well as nutrition advice. I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injury, spinal injuries, abnormal blood pressure responses and in rare instances heart attack or death. Protocols are followed to minimize these risks. Any information that is obtained regarding fitness level and progress will be treated as privileged and confidential and will not be released to any person other than my physician or physical therapist without my further consent. I have read and understand the foregoing consent to participation in said program. I am aware that I may discontinue my participation in this program at any time. In addition, I agree to the following: a. Assume all risk of injury and all risk of damage to or loss of property arising out of my participation in this program or visitation to the facility. b. Release, discharge and waive GJS47, LLC (dba: Great Jones Fitness) and its affiliates from any and all responsibility and liability of injury, including death which may be suffered by the undersigned arising out of, or in any way connected with the participation in this program. c. Indemnify and hold harmless any facility owned, operated or affiliated with GJS47, LLC (dba: Great Jones Fitness). d. All appointments require a 24 hour cancellation notice. Any appointments not cancelled within this period will be subject to a full charge for that session. All sessions purchased are non-refundable.

I acknowledge that I have read and agree to the above Terms and Conditions