Name:______________________________________
Street:______________________________________
City:_______________________________________
State:______________________________________
Zip:_______________
Profession: _________________________________
Email: _________________________________
Date of Birth ___/___/___
Home Phone
(_____)____________________
Work Phone (_____)_____________________
Fax Number (___)_______________________
E-mail _________________@_____________
I rate my current fitness level as a _____ (1-10), ten being high.
How did you hear about us? ______________________________________________________________________.
Emergency Contact
and phone number______________________________________________________
If you need to provide credit card information: (circle one) MasterCard
Visa otherwise ignore this section.
| Name on the Card: |
|
| Credit Card Number: |
|
| Card Expiration Date: |
|
| CVC
Code* |
|
| Your Signature:
|
|
*Visa
and Mastercard
In the signature box on the back of your Visa you should see a 16-digit credit
card number followed by a special 3 digit code. This 3 digit code is your CVC.
What is the name, location
& time of the program you are joining?
__________________________________________________
Price of program $ _____
If paying by check,
please make payable to BK Wellness Enterprises, Inc.
100 Richards Ave. #405, Norwalk, CT 06854. Waiver must be signed prior
to participation.
MEDICAL
HISTORY (If you are a returning camper, only complete the sections
that have changed.)
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
2. Do you take any prescribed medication on a permanent or semi-permanent
basis?
3. Do
you have a seizure disorder (epilepsy)? Yes No
4. Do you have diabetes Adult or Juvenile? Yes No
List Medications:
5. Have you ever been found
to be anemic (low blood count)? Yes No
6. Do you have High Blood Pressure (hypertension)? Yes No
List Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease: Yes No
Lung Disease: Yes No
Kidney Disease: Yes No
Liver Disease: Yes No
8. Do you have asthma? Yes No
List Medications:
9. Have you ever had a severe neck injury?
Describe:
10. Have you ever been knocked out?
Describe:
11. Do you wear glasses or contact lenses? Yes No
12. Have you had a broken bone or fracture in the past 2 years?
Describe:
13. Have you ever injured your back?
Describe:
14. Do you have back pain?
Never Seldom Occasionally
Frequently with vigorous exercise or heavy lifting
15. Have you had knee pain in the past 2 years that has disabled you for longer
than a week?
Describe:
16. Do you have other physical conditions which cause pain?
Describe:
17. Detail any surgical procedures:
18. What are your goals for the next three months?
19. Have you had your body fat tested?
If yes, what percent is it?
20. Are you training for a specific event?
If yes, explain:
NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition
program!
RELEASE
This release
is entered into between the undersigned and BK Wellness Enterprises,
its officers, subsidiaries, affiliates, and executors in addition to the City
of Norwalk. The purpose of
BK Wellness Enterprises is to provide fitness instruction and coaching
for various levels of athletes/individuals.
The undersigned
hereby acknowledge that the following was explained to me and/or agree to the
following:
1. Acknowledges
that Laura Krout is not a physician and is not trained in any way
to provide medical
diagnosis, medical treatment, or any other type of medical advice.
2. Acknowledges
that coaching/training is another tool for teaching athletes/individuals about
themselves,
but that BK Wellness Enterprises, LLC does not guarantee neither good
nor bad will occur nor guarantees the training advice given by BK Wellness Enterprises, LLC will produce good nor bad results.
3. Acknowledges
that the undersigned has been told if they feel tired, feel pain or feel out
of the ordinary
in any way either related to your training, or otherwise, that the undersigned
should contact a physician at once.
4. Acknowledges
that boot camps, aerobic classes, martial arts, kick boxing, running, kung-fu,
weight training,
obstacle courses, and any other related sports are an extreme test of one's
mental and physical limits and carry
with it potential for damage or loss of property, serious injury and death.
That the undersigned assumes the risks
of participating in these types of events/activities including the elements
of a natural environment, that they are fit, and they have a regular medical
physician they can contact regarding any medical problems that they might develop.
The undersigned expressly waive, release, discharge and agree not to sue from
any liability of death, disability, personal injury, or action of any kind BK Wellness Enterprises, LLC for the undersigned participating in said sporting
events and/or training for said sporting events.
The Undersigned
agrees that this is the full agreement between the parties, that BK Wellness Enterprises, LLC. nor anyone else has not verbally contradicted any of
the terms of this release and that the undersigned has entered into this
agreement free and voluntarily without force or coercion. I
____________________
Signature
____________________
Printed Name
____________________
Date