Welcome to Willspace Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Goals What are your top 3 outcomes fitness goals? Physical Activity Readiness Questionnaire Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you perform physical activity? * Yes No In the past month, have you had chest pain when you were not performing any physical activity? * Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No Have you ever had any joint pain or injuries (ankle, knee, hip, back, shoulder, etc.) * Yes No If yes, please explain Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? * Yes No If yes, please explain Waiver and Release * I hereby consent to engage in physical training that may include cardiovascular, resistance, stretching and other vigorous activities (the "activity" or "activities" hereafter) offered by Willspace Movement LLC. My participation in these activities is voluntary. I affirm that I do not suffer from any ailment that would be adversely affected by the activities. I affirm that all the information I have given pertaining to my current health status is reliable and accurate to the best of my knowledge. I understand that it is my responsibility to monitor my own condition throughout each training session and should anything unusual occur, I shall inform Willspace Movement LLC and consult with my physician. I hereby affirm that I am aware of the potential dangers and risks associated with the activities and therefore I agree to, subject to the foregoing paragraph, abide by all rules, guidelines and instructions provided by Willspace Movement LLC I hereby release, discharge, indemnify and hold harmless Willspace Movement LLC, its agents and substitutes, from any claims, demands, and causes of action arising from my participation in the activities. I am legally competent to sign this release or my parent or guardian has read and signed this release and given me permission to sign it. I agree to these terms. Initial & Date * Thank you!
