Medical History and Liability Waiver Step 1 of 7 14% About YouFirst Name(Required) Last Name(Required) Phone(Required)Email(Required) Birthday(Required) MM slash DD slash YYYY Age(Required)Occupation Address(Required) Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip ContactsMarital StatussingledivorcedmarriedwidowedSpouse’s Name Spouse’s NumberEmergency Contact Emergency Contact PhoneFamily Physician Physician Phone Medical HistoryHave you ever had...(Required)noneBack Injuries (Herniated Disc)Heart TroubleOperationsDiabetesHigh Blood PressureVaricose VeinsEpilepsyGoutDisease of Arteries (Aneurysm)Rheumatic Fever/Heart MurmerLung Disease (COPD)If yes, please explain...Has anyone in your family ever had...(Required)NoneHeart AttackHigh Blood PressureHigh CholesterolDiabetesKidney DiseaseStrokeOtherHeart Surgery/ProcedureGoutEpilepsyCongenital Heart DiseaseIf yes, please explain...Have you recently had any of these...(Required)NoneOrthopedic ProblemsBack PainShortness of BreathChest Pain/DiscomfortWaking At Night To UrinateArthritis, Swollen, Stiff or Painful JointsCough On ExertionHeart PalpitationsCoughing BloodIf yes, please explain...Are you taking or have you recently taken any of these?(Required)NoneDigitalis PreparationsAnti-Arrythmias (Quinidine, Procaine, Amides)Metabolics (Insulin, Thyroid, etc.)Beta BlockersDiuretics And ElectrolytesTranquilizers Or SedativesCalcium Channel BlockersIf yes, please explain...Are you currently taking ANY medications? If so, which? Do you smoke?noyesHow Long? How Often? What Kind? Goals & ActivityCurrent Bodyweight Weight One Year Ago Weight at 21 Are You Dieting?noyesDo you engage in physical activity?yesnoHow Often? What kind? How long are your workouts?0-15 Minutes15-30 Minutes30-45 Minutes45-60 Minutes60+ MinutesHow active is your job?ActiveHighly ActiveInactiveSedentaryDo you experience discomfort, shortness of breath or pain with moderate exercise? If so, please explain... Did you participate in school sports?yesnoWhat’s your primary goal for exercising?I don’t exerciseTo lose weightDoctor’s RecommendationFor Good HealthEnjoymentOtherHow would you describe your state of well being at this time?(Required)Please enter a number from 1 to 10.Enter a number between 1 and 10. Trainer PreferencesDo you have a preference for a male or female trainer?(Required)No PreferenceMaleFemaleHow many people are you planning to have in the session (including you)?(Required)Just meTwoThreeFourHow many times a week do you want to train?(Required)1233+What days of the week are you looking to train?(Required)SundayMondayTuesdayWednesdayThursdayFridaySaturdayWhat times of day are you looking to train?(Required)Early Mornings (5-8am)Mornings (8-11am)Early Afternoon (12-3pm)Late Afternoon (4-6pm)Evening (7-9pm)What city would you like to train in?(Required) What is your preference for the venue that you’ll train?(Required) Are you looking to workout at home, at a park, in a gym, at your office, etc?What style of training are you looking for?(Required)Strength TrainingConditioning (Cardio, Ropes, High Intensity, etc.)Cross Training (Strength & Conditioning)Functional (Resistance Bands, Correctional Exercises for Injuries/Mobility, etc.)Alternative (Boxing, Pool Workouts, etc.)Not SureDescribe the personality of the trainer you’re looking for:(Required)Kick my butt into shapeSupportive and patientDetailed with techniqueWorks well with kidsWorks well with injuries/illnessesHas an athletic backgroundWhat level of trainer do you want?(Required)Standard (For Individuals & Less Experienced Trainer)Advanced (1-4 People & More Experienced Trainers)How soon would you like to start?(Required) Do you have equipment as well? If so, what do you have?(Required) Is there anything else you’d like us to know when matching you with a trainer? NutritionWhat motivated you to seek out the help of a professional? What’s been your biggest frustration when trying to reach your goals?Where do you see yourself in 6 months if you do NOT commit to your transformation goals? On a scale of 1-10, how committed are you to reaching your transformation goals?Please enter a number from 1 to 10.Are you in a position to make a financial investment in this coaching program right now? Are you in a position to make a premium financial investment in this coaching program right now? Who would need to be present in our discovery call to make financial decisions? Spouse, friends, family, etc. CLIENT SERVICES AGREEMENT This Member Services Agreement (“Agreement”) is made and entered into between Health Professional Connect, a Florida corporation, doing business as FitnessAtYourDoor (the “Company”) and ___________________ (“Client”) (hereinafter collectively referred to as “Parties”). The Parties, therefore, agree as follows: Services. During the Term of this Agreement, the Company, through its contractors, will perform for the Client personal training services. Company, in collaboration with Client, will develop a personal training program suited to the needs of the Client and taking into account Client’s abilities, medical history, and goals for the duration of the training. Sessions. Client will have a number of personal training sessions based on the personal training package, membership, or subscription for which they have signed up. Payment. The Client shall pay the Company at a rate and at such times as more particularly described according to the personal training package, membership, or subscription for which they have signed up. Terms and Conditions. Personal training sessions that are not rescheduled or canceled 12 hours in advance will result in forfeiture of the session and a loss of financial investment at the rate of one session. Clients arriving late will receive the remaining scheduled session time unless other arrangements have previously been made with the Company. The expiration policy requires the completion of all personal training sessions within the 30 days after the end of the personal training package, membership, subscription. Personal training sessions are void after this time period. No personal training refunds will be issued for relocation, unused sessions, or reassignment of the Client to a new trainer. At the Company’s discretion, personal training sessions may be refunded due to illness of the Client. Client Understandings. Client understands that they will be required to complete a disclosure form including their health history, and agrees to do so accurately and completely, including disclosure of any prescribed medications they are taking and any exercise or diet limitation they are aware of or have been informed of by their physician. During the program, if Client’s medications condition or medical limitations should change, they will notify the Company. Client understands that by signing this agreement, Client agrees to observe and obey all written rules, regulations, and warnings of any training location and further agrees to follow any instructions or directions given by the Company, its affiliates, agents, employees, or contractors. The Client recognizes that the activities may involve strenuous physical activity, including but not limited to muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. Client acknowledges that the Company recommends that you consult a physician prior to participating in the personal training program or any other events sponsored by the Company. Client understands that the Company and its contractors are not physicians and cannot replace the advice and expertise of a physician. Client understands that exercise involves certain risks, including but not limited to, serious neck and spinal injuries resulting in complete or partial paralysis, heart attack, stroke, or even death. Also, injuries could occur to bones, joints, or muscles. Slips, falls, and unintended loss of balance could result in muscular, neurological, orthopedic, or other bodily injury. Client understands that part of the risk involved in undertaking any activity or program is relative to their own state of fitness or health (physical, mental, or emotional) and to the awareness, care, and skill that they conduct themselves in the personal training program. Client Representations About Health. Client attests that he or she is in good physical health and does not suffer any disability or condition known to Client that would prevent or limit Client from participating in the activities. Dress Code. The Client will wear proper attire during their participation in the personal training program, including appropriate exercise shoes and clothing. Publicity Waiver: Client hereby grants the Company the unrestricted right to use pictures or photographs of clients (still or moving), film, voice recording, statements and comments, in whole or in part, in any media, in perpetuity, throughout the world, to promote the Company and its services. Use of Equipment. During the personal training program, the Client will be instructed on the proper use and safety guidelines of all equipment used. Client acknowledges that they understand the importance of safe use of any exercise equipment associated with the personal training session and will at all times follow the proper use and safety guidelines. Reimbursement for Broken Equipment. Client agrees to reimburse the Company for the cost of any exercise equipment broken by Client due to misuse or negligence of the Client. Termination. The term of this Agreement will commence on the date of signing by both Parties (the “Effective Date”) and will continue until such time as either of the Parties terminate the Agreement or when all personal training sessions that have been paid for are used (“Termination Date”). Assumption of Risk. Client recognizes that there are certain risks associated with participation in the personal training program, and assumes full responsibility for any personal injury or death sustained by Client, or if applicable, Client’s minor child. and further releases and discharges the Company, its affiliates, agents, employees or contractors for any injury, loss, or damage arising out of Client’s or Client’s minor child’s use of equipment or participation in the personal training program whether caused by Client, or Client’s minor child, or other third parties. The Company will not be held responsible for any health-related issues, including but not limited to allergic reaction or personal injury due to consumption of suggested supplements, CBD products, nutritional plans, or prepared meals. These programs are not intended to diagnose, treat, cure or prevent any disease. Please consult a physician prior to starting the personal training program or participating in meal preparation services. Knowing the material risks and appreciating, knowing and reasonably anticipating that other injuries are a possibility, Client hereby expressly assumes all of the delineated risks of injury, all other possible risks of injury, and even risk of possible death, which could occur by reason of Client’s participation. Indemnification. Client shall defend, indemnify and hold Company and its successors, assigns, and licensees harmless from any and all claims, actions, and proceedings, and the resulting losses, damages, costs, and expenses (including reasonable attorneys' fees) arising from any claim, action or proceeding based upon or in any way related to Client’s, breach or alleged breach of any representation, warranty or covenant in this Agreement, and/or from the acts or omissions of Client. Limitation of Liability. Client hereby waives, releases, and discharges Company from any and all responsibilities or liability for any present and future injuries or damages arising from Client’s participation in any activities including but not limited to exercise, personal training, or the use of equipment, including any injuries and damages caused by the negligence of Company and its contractors. Attorneys’ Fees. If any action is brought relating to this Agreement, the prevailing party shall be entitled to recover reasonable attorneys' fees and costs of suit. Assignment. Neither this Agreement nor any duties or obligations under this Agreement may be assigned by Client to a third party without the prior written consent of the Company. It shall be binding upon and shall inure to the benefit of the Company and its successors and assigns, and its economic rights and benefits shall inure to the benefit of the Client or her heirs and duly constituted legal representatives. Severability. If any term or provision of this Agreement shall be held invalid or unenforceable to any extent, the remainder of this Agreement shall not be affected. Amendment. This Agreement may be amended only by written agreement, including but not limited to email, duly executed by an authorized representative of each party. Waiver. A failure or delay in exercising any right, power, or privilege in respect of this Agreement will not be presumed to operate as a waiver, and a single or partial exercise of any right, power, or privilege will not be presumed to preclude any subsequent or further exercise, of that right, power or privilege or the exercise of any other right, power or privilege. Binding Effect. This Agreement shall be binding on and shall inure to the benefit of the Parties hereto and their respective heirs, representatives, successors, and permitted assigns. Governing Law. This Agreement shall be governed by the laws of the State of Florida applicable to contracts made and to be performed in this state. Jurisdiction and Venue. The parties agree that the exclusive venue for any litigation, proceeding, claim, or controversy that arises out of or relates to the Client’s personal training sessions, this Agreement, or the breach of this Agreement, will be in the State of Florida. The parties each hereby submit to the jurisdiction at the state and federal courts in the State of Florida. Entire Agreement. This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings. [Signature Page Follows] By signing this Agreement, Client affirms and attests that they have read this agreement and has or will consult with a physician or medical doctor prior to beginning personal training sessions. FOR CLIENT _____________________________________ Date: ________________________________ Address: _____________________________ FOR COMPANY _____________________________________ Kashawn Fraser, Owner Date: ________________________________ Address: ____________________________ I have read this and fully understand it; I also understand that by submitting this form, I am voluntarily surrendering certain legal rights.(Required) The undersigned swears that the above information is true and correct to the best of his/her knowledge and recognizes that this assessment is not the equivalent of a medical evaluation or diagnosis. Signature (printed)(Required) Signature(Required) Reset signature Signature locked. Reset to sign again Please draw your signature.NameThis field is for validation purposes and should be left unchanged.