Personal Training Client Questionnaire

I wish to participate in the exercise and training program offered by Pines Fitness Consulting, LLC. (PFC). I understand there are inherent risks in participating in a program of strenuous exercise; consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. If I choose not to see a physician prior to beginning a fitness program, I do so strictly at my own risk and against recommendation of PFC. I also agree to provide PFC with my physician’s contact information so that PFC may receive direct clearance and program recommendation/limitations from my physician. I further agree that PFC, Chad Pines and/or any fitness professional working with PFC shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, in a training studio, outdoors, or at a corporate, commercial, residential or other fitness facility), and I expressly release and discharge PFC, its owners, employees, agents and/or assigns from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by an intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.*

I certify that the answers to the questions outlined on the About Your Health form are true and complete to the best of my knowledge. I acknowledge that medical clearance is requested if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform PFC of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.*

I understand that I am not obligated to perform nor participate in any activity that I do not wish to do. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and seek medical attention, if required.*

I understand the results of any fitness program cannot be guaranteed and my progress depends on my own effort and cooperation with the fitness program. *

I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by PFC.*

I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.*