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:
