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All information received on this form will be treated as strictly confidential. Please fill out  the forms completely and accurately. This information is essential to helping us  assess your needs, goals and interests, and is safe and effective.  

Name: {name} Date of Birth: {dob} Age: Address: {address} Phone: (h) Email address: {email}  Occupation: Emergency Contact: {contact_name required} Relationship: {contact_relation}  Emergency Contact Phone Number: {contact_phone}  

911 Fitness, LLC 

420 Jay Bird Ln 

Springtown, Tx 76082 

972-885-8692 

Gym911fitness@gmail.com

PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT 

1. I, {name}, wish to participate in the  exercise and training program offered by 911 Fitness. 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 below. 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. I agree that  911 Fitness, LLC shall not be liable or responsible for any injuries to me resulting from  my participation in the fitness program (whether at home, at the training studio, outdoors,  or at a corporate, commercial, residential or other fitness facility) and I expressly release  and discharge 911 Fitness, LLC, its owners, employees, agents and/or assigns, 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 an injury  caused by the gross negligence or intentional act of such person or persons. This  Release shall be binding upon my heirs, executors, administrators and assigns.  

I have read and understand this term:  (initial)

2. I certify that the answers to the questions outlined on the PAR-Q form are true and  complete to the best of my knowledge. I acknowledge that medical clearance is required 

if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and  agree that it is my responsibility to inform my Trainer of any conditions or changes in my  health, now and on going, which might affect my ability to exercise safely and with  minimal risk of injury.  

I have read and understand this term: (initial)    

3. 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 my Personal Trainer.  

I have read and understand this term: (initial)  

4. I understand the results of any fitness program cannot be guaranteed and my  

progress depends on my effort and cooperation in and outside of the sessions. I have  read and understand this term:   (initial)  

5. I understand that Progress Fitness bills its Personal Training clients on a pre-pay basis.  Once my trainer and I have decided upon the type of training package and payment plan  I will purchase, payment must be made before the sessions are conducted. Credit cards,  cash, and checks made payable to Progress Fitness are all accepted. I understand that  all Personal Training sessions are non-refundable.  

I have read and understand this term: (initial)

6. I understand that Progress Fitness operates on a scheduled appointment basis for all  Private Training sessions and thus, requires that I provide 24 hours notice when  canceling an appointment. No charge will be levied should I cancel with MORE than 24  hours notice given. Should I cancel a session without 24 hours prior notice, I will be  charged in full for that session. I understand that Progress Fitness recommends that all  cancelled sessions be rescheduled to ensure consistency and fitness progress.  

I have read and understand this term:  (initial)  

7. I understand that the usage of any nutritional supplements is done under my own will  and has not been prescribed by my Personal Trainer.  

I have read and understand this term: (initial)  

8. I understand that Progress Fitness photographs many of their client events/sessions and  I provide written approval for them to use these pictures for promotional purposes.  

I have read and understand this term: (initial)  

I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily  and with full knowledge of its significance. 

                      {sign_date}