$115 DOLLARS/MONTH

Name *

Email Address

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

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Emergency Contact Name

Phone

Relationship

Phone

Emergency Contact Name

Relationship

Media ReleaseYes, I agree to allow my media to include images and videos to be used by BBB.No, I do not agree to allow my media to include images and videos to be used by BBB.By opting in to Bams Banging Body Fitness Media Use, you agree that images of your progress may be used across web promotions, social media platforms and any other form of advertisement gateway created by BBB. You understand that you will receive no monetary compensation for use of aforementioned media and will not pursue payment for it’s use.

Physician Name

Physician Phone

Health Questionnairre

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

YesNoPlease Mark Yes or No:

In the past month, have you had chest pain when you were not doing physical activity?

YesNoPlease Mark Yes or No:

Do you feel pain in your chest when you do physical activity?

YesNoPlease Mark Yes or No:

Are you pregnant now or have given birth within the last six months?

YesNoPlease Mark Yes or No:

Do you lose your balance because of dizziness or do you ever lose consciousness?

YesNoPlease Mark Yes or No:

Have you had a recent surgery?

YesNoPlease Mark Yes or No:

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory aliments, back problems, etc)?

YesNoPlease Mark Yes or No:

Do you take any medications, either prescription or non-prescription, on a regular basis?

YesNoPlease Mark Yes or No:

If Yes, What is the Medication For?

Do you know of any other reason why you should not do physical activity?

YesNoPlease Mark Yes or No:

If you answered yes to any of the above questions, please use this area to explain.

Initial *I wish to participate in the exercise and training program offered by BBB. 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. 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. I also agree to provide BBB with my physician’s contact information so that BBB may receive direct clearance and program recommendations/limitations from my physician. I further agree that BBB shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, outdoors or in any fitness facility), and I expressly release and discharge BBB 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 and injury caused by an intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.0 / 3

Initial *I understand that BBB will make every reasonable effort to preserve the privacy of the information contained in this Client Intake Form. I further agree that BBB shall not be liable or responsible to me for any inadvertent disclosure of the information contained in the Client Intake Form and I expressly release and discharge BBB from all claims, actions, judgment and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any damage which may occur in connection with disclosure of private information contained in the Client Intake Form. This release shall be binding upon my heirs, executors, administrators and assigns.0 / 3

Initial *I certify that the answers to the questions outlined on the CLIENT INTAKE 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 CLIENT INTAKE form. I understand and agree that it is my responsibility to inform BBB of any condition or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.0 / 3

Initial *I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform BBB. 0 / 3

Initial *I understand that the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.0 / 3

Initial *I understand that services at Bodied By Bam / Bam’s Banging Body Fitness, once purchased are non-refundable and non-transferrable between clients/classes/sessions.0 / 3

NameI UNDERSTAND THAT BY TYPING MY NAME HERE I AM DIGITALLY SIGNING THIS FORM AND ACCEPTING ALL TERMS AND AGREEMENTS

LAST 4 DIGITS OF SSN *I UNDERSTAND THAT BY ENTERING THE LAST 4 DIGITS OF MY SSN I AM ACCEPTING ALL TERMS AND AGREEMENTS

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