HEALTH INTAKE FORM
Profile Info
Name {name} Phone (Mobile) {phone} Email address {email}
Home Address {address}
Emergency contact: Name / Relationship {contact_name}/{contact_relation} Phone {contact_phone}
What brings you here? If we waved a magic wand to flash 3 or 12 months from now, what changes would you like to see - what do you want to achieve?
Why do you want to achieve it?
What fitness places, diets and workout programs have you tried before?
How many days a week are you currently working out? How many would you like to?
General Comments/Questions?
How did you hear about us: Referred By:
Are you interested in being eligible for a discount? Just list the names and contact info of friends, co- workers or family members who would be interested in Dream Athletics.
Name|Cell|Email: Name|Cell|Email:
Please answer the following health questions by checking the appropriate box
Are you a male over 45 or a female over 55 who has previously been inactive?YES NO
Has your doctor ever said that you have a heart condition and that physical activity is recommended from him/her only? YES NO
Have you had a heart attack or stroke? YES NO
Do you feel pain in your chest when you do physical activity? YES NO
In the past month, have you had any chest pain when not doing physical activity? YES NO
Do you lose your balance due to dizziness or do you ever lose consciousness? YES NO
Do you have a bone or joint problem that could be made worse by physical activity? YES NO
Has a doctor ever said that your blood pressure is too high? YES NO
Is your doctor currently prescribing drugs for high blood pressure or heart disease for you? YES NO
Is there any other good medical reason not mentioned here that would affect your ability to train? YES NO
If Yes, what?
Is there anything else we should know about you physically? (i.e., chronic low back pain, knee/ankle/hip/shoulder issues, recent surgeries, doctor- recommended
limitations, etc.)
WAIVER, RELEASE, AND ASSUMPTION OF RISK
This Release of Liability Agreement (“Agreement”) is between you the client (“Client”) and Dream Athletics, on behalf of itself and its related companies, affiliates and subsidiaries (collectively, “Dream Athletics”). It is agreed by the parties that Client is purchasing, for the benefit of Client, a fitness program membership, from Dream Athletics, according to the terms hereof and the Dream Athletics Membership Agreement.
Client has volunteered to participate in a physical fitness program provided to me by Dream Athletics, which may include, but may not be limited to, strength training, mobility & flexibility training, cardiovascular exercise and nutritional service programing (the “Fitness Program”).
IMPORTANT NOTICE:
In consideration of Dream Athletics' agreement to provide the Fitness Program, I agree to release Dream Athletics from liability due to participation. CLIENT IS URGEDTO HAVE THIS RELEASE AGREEMENT REVIEWED BY THEIR ATTORNEY BEFORE SIGNING.
CLIENT ACKNOWLEDGES THAT THE FITNESS PROGRAM PURCHASED HEREUNDER INCLUDES PARTICIPATION IN STRENUOUS PHYSICAL ACTIVITIES, INCLUDING, BUT NOT LIMITED TO, RUNNING, WEIGHT TRAINING, VARIOUS AEROBIC CONDITIONING, MACHINERY AND VARIOUS NUTRITIONAL PROGRAMS OFFERED BY DREAM ATHLETICS CLIENT ACKNOWLEDGES THESE PHYSICAL ACTIVITIES INVOLVE THE INHERENT RISK OF PHYSICAL INJURIES OR OTHER DAMAGES, INCLUDING, BUT NOT LIMITED TO, HEART ATTACKS, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEAT EXHAUSTION, KNEE/LOWER BACK/FOOT INJURIES AND ANY OTHER ILLNESS, SORENESS, OR INJURY, HOWEVER CAUSED, OCCURRING DURING OR AFTER CLIENT'S PARTICIPATION IN THE FITNESS
PROGRAM. CLIENT FURTHER ACKNOWLEDGES THAT SUCH RISKS INCLUDE, BUT ARE NOT LIMITED TO, INJURIES CAUSED BY THE NEGLIGENCE OF AN INSTRUCTOR OR OTHER PERSON, DEFECTIVE OR IMPROPERLY USED EQUIPMENT, MACHINERY, DEVICES OR FURNITURE, OVER-EXERTION, SLIP AND FALL, OR AN UNKNOWN HEALTH PROBLEM AND THAT CLIENT IS VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES AND USES ANY EQUIPMENT, MATERIALS, DEVICES, FURNITURE OR MACHINERY WITH FULL KNOWLEDGE, UNDERSTANDING AND APPRECIATION OF THE DANGERS INVOLVED. CLIENT HEREBY AGREES TO EXPRESSLY ASSUME AND ACCEPT ANY AND ALL RISKS OF INJURY, REGARDLESS OF SEVERITY, OR DEATH.
CLIENT AGREES TO ASSUME ALL RISK AND RESPONSIBILITY ARISING FROM PARTICIPATION IN THE FITNESS PROGRAM. CLIENT AFFIRMS THAT CLIENT IS IN GOOD PHYSICAL CONDITION AND DOES NOT SUFFER FROM ANY DISABILITY THAT WOULD PREVENT OR LIMIT PARTICIPATION IN THE FITNESS PROGRAM. CLIENT ACKNOWLEDGES PARTICIPATION WILL BE PHYSICALLY AND MENTALLY CHALLENGING, AND CLIENT AGREES THAT IT IS THE RESPONSIBILITY OF CLIENT TO SEEK COMPETENT MEDICAL ADVICE REGARDING ANY CONCERNS OR QUESTIONS CONCERNING THE ABILITY OF CLIENT TO TAKE PART IN THE FITNESS PROGRAM. BYSIGNING THIS AGREEMENT, CLIENT AFFIRMS THAT HE OR SHE IS CAPABLE OF PARTICIPATING IN THE FITNESS PROGRAM. CLIENT AGREES TO ASSUME ALL RISK AND
RESPONSIBILITIES FOR EXCEEDING HIS OR HER PHYSICAL LIMITS.
CLIENT, ON BEHALF OF CLIENT, HIS OR HER HEIRS, ASSIGNS AND NEXT OF KIN, WAIVES ANY CLAIMS AGAINST AND RELEASES DREAM ATHLETICS AND ALL AFFILIATES (AS WELL AS ANY OF THEIR RESPECTIVE OWNERS, EMPLOYEES, OR OTHER AUTHORIZED AGENTS, INCLUDING INDEPENDENT CONTRACTORS) FROM ANY AND ALL LIABILITY, CLAIMS AND/OR CAUSES OF ACTION THAT CLIENT MAY HAVE FOR INJURIES OR OTHER DAMAGES OF ANY KIND, INCLUDING BUT NOT LIMITED TO PUNITIVE DAMAGES, ARISING OUT OF PARTICIPATION IN THE FITNESS PROGRAM, INCLUDING, BUT NOT LIMITED TO THE PERSONAL TRAINING/ NUTRITIONAL PROGRAMS AND ALL PHYSICAL ACTIVITIES.
CLIENT ACKNOWLEDGES THAT CLIENT HAS THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTANDS THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, CLIENT WAIVES ANY AND ALL RIGHTS CLIENT OR CLIENT’S SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST DREAM ATHLETICS OR ANY OF ITS AFFILIATES FOR THEIR NEGLIGENCE OR THAT OF THEIR EMPLOYEES, AGENTS, OR CONTRACTORS.
Client agrees that all terms and conditions of this Agreement shall be binding upon the heirs, personal representatives, lawful successors, and assigns of Client, and anyone claiming by or through Client.
The parties agree that if any provision or portion of this Agreement is declared void and unenforceable, such provision or portion of a provision shall be deemed severed from this Agreement, which shall otherwise remain in full force and effect. However, Client specifically agrees all the terms and conditions are to be enforced and Client specifically waives any statute or other right of any type, which would invalidate the enforceability of any provision or portion of a provision of this Agreement.
This Agreement shall be governed and enforced in accordance with the laws of the State of Pennsylvania In the event litigation is necessary to enforce any of the terms and conditions of this Agreement, the parties agree that the venue for such action shall exclusively be Luzerne County, Pennsylvania. Furthermore, in the event either party finds it necessary to commence litigation or other court action to enforce the terms and conditions of this Agreement, the prevailing party in such litigation or court action shall be entitled to receive their actual attorney’s fees incurred, together with court costs, and other charges from the other party as a part of any ruling or judgment.
I, Client, {name} have read, understood and completed this questionnaire honestly and to the best of my knowledge. I understand that Dream Athletics assumes no liability for persons who undertake physical activity.
{sign_date}
MEMBERSHIP AGREEMENT
Adult Name Phone (Mobile){phone} Email address {email}
Billing address {address}
Athlete Name (if not the same) Athlete Birthdate:
Membership Information:
Membership Type (Circle one):BCPrivate - Semi Private Youth Performance Sports Performance Adult Performance
Promotion:____________ Other: ______________________ Price (per month or in full): __________________________
Membership Package & Term Chosen: ____________________________________________________________________
Date Start: ____________________________________ Date Renew: _____________________________________
This Membership Agreement (“Membership Agreement”) is between you and Dream Athletics, on behalf of itself and its related companies, affiliates and
subsidiaries (collectively, “Dream Athletics").
BUYERS RIGHT TO CANCEL: If you wish to cancel this Agreement, you may cancel by mailing or delivering written notice by certified or registered mail to the address shown on the top of this agreement. The notice must say that you do not wish to be bound by this Agreement and MUST BE DELIVERED OR MAILED BEFORE MIDNIGHT OF THE THIRD BUSINESS DAY AFTER YOU SIGN THIS AGREEMENT. If cancelled within three business days, you will be entitled to a refund of all moneys paid. You may also cancel this Agreement if you relocate your residence further than 50 miles away from any Dream Athletics location or if Dream Athletics ceases operation at the location where you entered into this contract. If you become disabled, you shall have the option of being relieved of the liability for payment on that portion of the contract term for which you are disabled. Requests must be accompanied by a doctor’s certificate, which shall be enclosed with the written notice of disability. Dream Athletics may require that you be examined by another physician agreeable to you and Dream Athletics at its expense. If you cancel, Dream Athletics may keep or collect an amount equal to the fair market value of the services or use of facilities you
have already received.
TERMS & CONDITIONS of Membership
I hereby grant Dream Athletics permission to use my likeness in photograph(s)/video in any and all of its publications and in any and all other media for ethical promotional purposes, whether now known or hereafter existing, controlled by Dream Athletics in perpetuity, and for other use by Dream Athletics I will make no monetary or other claim against Dream Athletics for the use of the photograph(s)/video.
Insufficient funds/declined payments: Please note that you will be held responsible for credit fees if your billing account has insufficient funds or declined payments. You will be charged the credit card re processing fee of $1.50 for each occurrence. You will also be charged any other fees levied by Dream Athletic's financial institutions.
Clients may put their membership on hold (a/k/a a “freeze”) for any reason for either one time period of 30 consecutive days OR two time periods of 14 consecutive days during the length of the membership. You must notify Dream Athletics in writing of the dates you wish to put your membership on hold. During this freeze period you will not be billed your regular monthly dues and you may not use our facilities or any of our programs or services. Following the expiration of your freeze period, you will automatically be billed your regular monthly dues. Your commitment period will be extended by the amount of time your membership is on hold.
Dream Athletics reserves the right to cancel all Bootcamp sessions and Small Group Personal Training sessions should severe weather occur, a national holiday, an emergency or bizarre scheduling issue arise. Dream Athletics facilities and On-Site Training close on Easter, Memorial Day, 4th of July, Christmas and New Years Day. There is a limited schedule on New Years Eve, Labor Day, Thanksgiving and Christmas Eve. Bootcamp sessions and Small Group Personal Training sessions are not rescheduled. Private and Semi Private Training sessions will be rescheduled at mutual agreed upon time.
Your first payment will be made on the FIRST DAY of your paying membership.
TERMS & CONDITIONS Specific to Members Who Paid In Full Only (do not pay monthly)
All memberships are final three days after you sign this agreement and begin on the first day of your membership.
You can renew your current Paid In Full Rate for any 3, 4, 6, 8 or 12 month Memberships at the Dream Athletics Facility in Kingston, PA by resigning one month prior to the end of this agreement. 30-DAYS NOTICE is REQUIRED via email to 2016dream.fitness@gmail.com. There is no cancellation of Paid In Full Memberships. Sale is final three days after you sign this agreement and refunds cannot be issued.
Promotional Paid in Full Memberships such as a 7, 10 or 21 day, one month, 8 week or 3 month front end offer are only valid for people new to Dream Athletics and are limited to one per person. There is no cancellation of Promotional Front-End Offers. Sale is final three days after you sign this agreement. At that point refunds cannot be issued.
Dream Athletics and I, {name}, hereby agree to the terms and conditions of this contract
signed {sign_date} (day/month/year). I authorize Dream Athletics to process on my account due date all charges I have incurred for the previous month, if any, as well as all monthly fees that are due for the upcoming month.
___________________________________________________________________________________________________________
Client Signature or Parent / Guardian Signature (if client under age 18) Please Print Name Date
____________________________________________________________________________________________________________
Dream Athletics Representative Please Print Name Date
Dream Athletics Gym