Personal Information
Name *
Name
Phone *
Phone
Birth Date
Birth Date
(Must be at least 18 years old. Any client age 55 and over will be required to have their doctor fill-out a Physician's Clearance Form and be cleared to attend a boot camp type fitness of program. Once completed, form must be received by Big Mike's Ultimate Beach Workout at least (2) working days prior to attending Orientation date for verification.)
Address *
Address
Workout Package Information
Emergency Contact #1
Name #1 *
Name #1
Phone #1 *
Phone #1
EMERGENCY CONTACT #2
Name #2 *
Name #2
Phone #2 *
Phone #2
FITNESS TRAINING HISTORY
Physical Activity Readiness Questionnaire (PAR-Q)
Primary Physician - Name *
Primary Physician - Name
Primary Physician - Phone *
Primary Physician - Phone
Health History
Please read each question carefully. Physical activity should not be hazardous for most people. The questions are designed to identify those who should consult a physician prior to beginning a program of physical exercise.
1. Has a doctor ever said you have a heart condition and recommended medically supervised physical activity? *
2. Do you have chest pain brought on by physical activity? *
3. Do you tend to lose consciousness, feel faint or have spells of dizziness? *
4. Has your doctor recommended medication for blood pressure? *
5. Do you have a bone or joint problem (such as arthritis) that could be aggravated by physical activity? *
6. Are you aware, through your own experiences or a doctor’s advice, of any other physical reason against your exercising without medical supervision? *
7. Are you over the age of 55 and not accustomed to vigorous exercise? *
If you answered YES to one or more of the questions (1-7) above, please answer the following questions:
Have you consulted your physician regarding increasing your physical activity and or performing a fitness assessment? *
If NO, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?
Please check ALL medical conditions that apply to you: *
Release and Waive of Liability
MEMBERS ACKNOWLEDGEMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF BIG MIKE'S ULTIMATE BEACH WORKOUT. Member acknowledges that the personal training/fitness assessment hereunder includes participation in strenuous physical activities, including but not limited to, aerobic movement, sandbag weight training, running, sprinting, body-weight exercises, various aerobic conditioning, maximum fitness testing and various nutritional programs offered by BIG MIKE'S ULTIMATE BEACH WORKOUT. Member agrees to assume all risk and responsibility involved with participation in the physical activities. Member affirms that he/she is in good physical condition and does not suffer from any disability that would prevent or limit participation in physical activities. Member acknowledges that participation will be physically and mentally challenging, and member agrees that it is the responsibility of the member to seek competent medical or other professional advice, regarding any concerns involved with the ability of member to take part in BIG MIKE'S ULTIMATE BEACH WORKOUT physical activities. Member agrees to assume all risks in responsibility for not exceeding his/her physical limits. *
Type Your Name to Verify Agreement *
Type Your Name to Verify Agreement
Date of Agreement *
Date of Agreement
Client Consent Form - Big Mike's Ultimate Beach Workout
Please read the information below carefully and print and your name at the bottom of this form to AGREE. By signing this Consent Form, you are fully agreeing to the stipulations and requirements of your Boot Camp Training Program.
CLIENT CONSENT FORM - BIG MIKE'S ULTIMATE BEACH WORKOUT. I AGREE to abide by the following stipulations and rules for BIG MIKE’S BIG MIKE’S ULTIMATE BEACH WORKOUT program that I have chosen to participate in. I AGREE to participate in BIG MIKE’S ULTIMATE BEACH WORKOUT Program for the previously agreed-upon fee. I UNDERSTAND that I am NOT able to cancel my membership prior to the end of my current boot camp Workout Package, that I choose. If I try to do this, I am still liable for all monthly payments due for my current boot camp package. I also am aware that a different boot camp instructor can be assigned to work with me at any time as deemed necessary by BIG MIKE’S ULTIMATE BEACH WORKOUT. I understand that BIG MIKE’S ULTIMATE BEACH WORKOUT is not a medically supervised program and that BIG MIKE’S ULTIMATE BEACH WORKOUT Program was developed for healthy people with no medical conditions or risks, either physical or psychological. In addition to the terms above, I represent that I am in good physical condition and have no medical reason or impairment that might prevent me from participating in this Program. As such, I acknowledge that BIG MIKE’S ULTIMATE BEACH WORKOUT did not give me medical advice before this program, and cannot give me any after the Program, related to my physical condition and ability to participate. If I have any health or medical concerns now of after the Program, I will discuss them with my doctor. The information provided to me in any testing provided by BIG MIKE’S ULTIMATE BEACH WORKOUT is not intended to diagnose, treat, cure or prevent any disease or give medical advice of any kind. If I have an existing medical condition, before I can begin, I will present BIG MIKE’S ULTIMATE BEACH WORKOUT with a Physician's Clearance, medical release form, signed and dated by my personal physician. This Consent Form represents my physician’s approval to participate in BIG MIKE’S ULTIMATE BEACH WORKOUT. I grant permission to BIG MIKE’S ULTIMATE BEACH WORKOUT to contact my physician/dietician or health care professional if I require medical supervision during my participation in the Program. BIG MIKE’S ULTIMATE BEACH WORKOUT program is designed to help participants achieve their fitness goals by altering or maintaining body composition through proper application of all of the components of fitness. The Personal Training Program focuses on changes in body composition and circumference measurements, not weight loss. During the Program, I should not expect to lose more than a maximum of two pounds a week. Using BIG MIKE’S ULTIMATE BEACH WORKOUT program and any facilities or equipment utilized during that training involves the risk of injury to me, whether I or someone else causes it. Specific risks vary from one activity to another and the risks range from minor injuries to major injuries, such as catastrophic injuries including death. In consideration of my participation in the activities offered by BIG MIKE’S ULTIMATE BEACH WORKOUT, I understand and voluntarily accept this risk and agree that BIG MIKE’S ULTIMATE BEACH WORKOUT, its officers, directors, employees, volunteers, agents and independent contractors will not be liable for any injury, including, without limitation, personal, bodily, or mental injury, economic loss or any damage to me, my spouse (or domestic partner), guests, unborn child, or relatives resulting from the negligence of BIG MIKE’S ULTIMATE BEACH WORKOUT , whether related to exercise or not. Further, I understand and acknowledge that BIG MIKE’S ULTIMATE BEACH WORKOUT is providing recreational services and may not be held liable for defective products or equipment. This Consent Form is not effective until it is signed and dated. By signing below I acknowledge and agree that I have read the foregoing and know of the nature of the activities provided by BIG MIKE’S ULTIMATE BEACH WORKOUT and I agree to all of the terms of this Consent Form and acknowledge that I have received a copy of it.
Type Your Name to Verify Agreement *
Type Your Name to Verify Agreement
Date of Agreement
Date of Agreement
Performance Pledge and Release Form
In the spirit of harnessing your best effort and providing optimum results from your ULTIMATE BEACH WORKOUT experience, we have established the following policies to which you will need to adhere. Please read and check each one.
I agree not to use foul language or consume alcohol during Boot Camp. *
I agree not eat or say the words Meatball Sub, Cheetos, Chocolate or “All You Can Eat” during your Beach Workout. *
I will arrive at camp ON TIME (at least 5 minutes prior to the official start of my beach workout).* *
I understand that my “before” photo will be taken my first day at boot camp Orientation and will not be used for any promotional purposes unless I give written authorization. I also, understand that photos or video of me may be taken during the course of my involvement in Boot Camp, which may be used for promotional purposes by BIG MIKE'S ULTIMATE BEACH WORKOUT. *
I understand there is no refund policy, but I can receive a credit (for unused portion of camp) towards a future camp if, for reasons beyond my control, I am not able to complete the one I originally joined. Camp fees cannot be used towards any other products or services provided by BIG MIKE'S ULTIMATE BEACH WORKOUT. *
I agree to be subscribed to the Ultimate Beach Workout mailing list to receive team information, weather notifications, special events updates and the UBW Newsletter. *
My Personal Fitness Goal Pledges
I Agree to Attend BIG MIKE'S ULTIMATE BEACH WORKOUT: at least 3 times per week. No excuses. *
I Agree to keep an eye on my diet and do my best to stick to my Daily Calorie Target! *
I Agree to keep a food journal for a minimum of (2) weeks so that I can get a handle on just how many calories am consuming on a daily basis. *
I have read the Performance Pledge and Release Form and AGREE to ALL terms. *
Verify Entire Agreement
Type Name to Verify Agreement *
Type Name to Verify Agreement
Date of Agreement *
Date of Agreement