Name:
Email Address:
Phone Number:
Work Number:
Fax Number:
Address:
City:
State:
Zip Code:
Profession:
Date of Birth:
I rate my current fitness level as a:
I was referred by:
Emergency contact and phone number:
Choose the program you are joining:
Select One
Weston/Davie (Vista View Park) 9:30 am
Pembroke Pines (Chesterbrook Academy) 6:00am
Pembroke Pines (Chesterbrook Academy) 6:30pm
Kids Camp (Chesterbrook Academy) 8:00am
MEDICAL: (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)?
4. Do you have diabetes Adult or
Juvenile?
List Medications:
5. Have you ever been found to be anemic (low
blood count)?
6. Do you have High Blood Pressure
(hypertension)?
List Medications:
7. Do you have or have you ever had
the following diseases?
Heart Disease:
Lung Disease:
Kidney Disease:
Liver Disease:
8. Do you have asthma?
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?
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?
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
doctor’s advice before beginning any
health/fitness/nutrition program!
RELEASE
911
FITNESS , its officers,
subsidiaries,911 FITNESS
is to provide fitness
instruction and coaching for various
levels of athletes/individuals.
Acknowledges that Jim
Sayih, LEAD Trainer for
911 FITNESS, is not a physician and is not
trained in any way to provide
medical
diagnosis, medical treatment, or any
other type of medical advice.
Acknowledges that
coaching/training is another tool
for teaching athletes/individuals
about themselves,
but that does not guarantee
neither good nor bad will occur nor
guarantees the
Acknowledges that the undersigned
has been told if they feel tired,
feel pain or feel out of the
ordinary
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,
The undersigned expressly waive,
release, discharge and agree not to
sue from any liability of death,
disability,
personal injury, or
action of any kind Jim
Sayih or 911 Fitness 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 911 FITNESS and
Jim Sayih, 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.
By typing your name in this
field, you are hereby giving a
digital signature.
Signature
Today’s Date:
Comments/Questions:
