Intake Forms - Core Mobility Fitness

Personal Information

PLEASE FILL OUT THIS FORM TO THE BEST OF YOUR ABILITIES AND SIGN THE STATEMENT AT THE BOTTOM OF THE FORM. IF YOU HAVE ANY QUESTIONS, PLEASE FEEL FREE TO ASK.

Last Name *

First Name *

Phone

Email *

Gender *

Age *

Marital Status

Address

Apt, suite, etc.

Country

City

State

Zip code

Emergency Contact Name *

Emergency Contact's Phone *

Health/Exercise Information

Hobbies/Recreational Activities and Frequency: *

What do you do for work? *

How many hours a day do you:

Stand? *

Sit? *

Walk? *

Exercise? *

Drive? *

Sleep? *

General Health: *

Excellent

Good

Fair

Poor

Personal Fitness Goals: *

Signature and Submit

I, THE UNDERSIGNED, DO HEREBY CERTIFY THAT I HAVE COMPLETED THE ABOVE INFORMATION AND KNOW IT TO BE TRUTHFUL AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

Signature: *

Type your name to "sign" this form.

Date *

CMF Waiver

I will receive information and instruction while participating in the class, health program, or workshop offered by Core Mobility Fitness Studio. *

I recognize that this class will require physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

Yes

I understand that it is my responsibility to consult with a physician prior to and regarding my participation in this class or any other activity associated with Core Mobility Fitness Studio. *

I represent and warrant that I am physically fit and have no medical conditions that would prevent my full participation in the class, health program, or workshop.

Yes

I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I may incur as a result of participating in the program. *

Yes

I knowingly, voluntarily, and expressly waive any claim that I may have against Core Mobility Fitness Studio for injuries or damages that I may sustain as a result of my participation. *

Yes

Heirs, my legal representatives, and I forever release and waive any liabilities against Core Mobility Fitness Studio for any injury or death incurred by my voluntary participation in this class, workshop, or activity. *

Yes

I am not experiencing any fever, headaches, or any other flu like symptoms at this time. *

Yes

I HAVE READ THE ABOVE RELEASE AND WAIVER OF LIABILITY AND FULLY UNDERSTAND THEIR CONTENTS. I VOLUNTARILY AGREE TO THE TERMS AND CONDITIONS STATED ABOVE.

Your Name *

Type your name to acknowledge this policy.

Date *

Phone *

Email *

Core Mobility Fitness

4185 Technology Forest Blvd, Suite 125
The Woodlands, TX 77381

Tel: 503-575-8145

Email:
be.empowered.cmf@gmail.com

Personal Information

Health/Exercise Information

Medical Information

Signature and Submit

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