Client Details* Name * Nick Name * Date of Birth* YYYY slash MM slash DD Sex* Male Female Address* Address Line Address Line 2 City State/Province/Region Zip/Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Occupation* Email* Mobile*Phone Number *Emergency Contact* Emergency Contact NameEmergency Mobile* Emergency Contact NameHow did you hear about Team Impaact?* Friend Family Facebook Instagram Internet Flyer Sign Do you have any friends or family that would like to experience what we have to offer here at T.I. with you? If so, what are their names?What are you hobbies?Do you have any children? If so, what are their names and ages?Do you have any pets? If so, what are they and what are their names?Training HistoryI am* New To Exercise Somewhere In The Middle Experience Currently Exercising?* Yes No Times Per Week?* 1 2 3 4 5 6 7 Consistent?* Yes No Achieving Results* Yes No Do You Like To Train In The Morning Or Afternoon?* Am Pm On A Scale Of 1-10 1 = Poor, 10 = Excellent, How would You Rate Your Current Fitness?* How long ago were you in your best condition?*What were you doing differently back then?*CURRENT LIFESTYLE Do you have a stressful job?* Yes No What is your current work / study schedule?*Do you drink alcohol?* Yes No Do you smoke?* Yes No Do you drink coffee?* Yes No Food Intolerance?* Yes No How would you rate your nutrition on a scale of 1-10?*How would you rate your sleep on a scale of 1-10?*1 = poor, 10= goodHow many nights per week do you eat out, and what types of food?*MEDICAL CONDITIONS High blood pressure?* Yes No Chest Pain* Yes No Back Pain* Yes No Heart trouble/history* Yes No Epilepsy* Yes No Asthma* Yes No Faint or dizzy spells* Yes No Arthritis* Yes No Sports injury* Yes No Bone or joint problem* Yes No Diabetes* Yes No Other* Yes No HEALTH & FITNESS PRIORITIESWeight Loss Loss Weight Shape and Tone Reduce body Fat Decrease Clothing Size HiddenWould you like to achieve these? Lose Weight Shape and Tone Reduce body Fat Decrease Clothing Size Fitness Increase Endurance Sporting Performance Wellness Stress Management Increase Flexibility Rehabilitation Strength Increase Strength Increase Muscle mass Increase Stamina What are your 3/6/12 month goals?3 Months* 6 Months* 12 Months* Why do you want to achieve these results?*When do you want to achieve these by?*How long do you think it will take you to achieve your goals?*Which part of the body would you like to achieve these results In?*How long have you been thinking about achieving your results?*Are you 100% committed to achieving your why?* Yes No Are you willing to make sacrifices in order to achieve your why?* Yes No What is your budget and what are you willing to invest into your health and fitness?*Personal Barrier Please Check* Time Money Procrastination Motivation Injury None Is this still a problem?* Yes No Do you have support from your friends and family?* Yes No Life values & what are you grateful for?*Fears*Terms & Conditions 1st Session comfort guarantee If you change your mind, you can terminate this agreement within 48hrs after your first paid group and PT session with team Impaact. Email teamimpaact2017@gmail.com and we will cancel all future payments and refund to you within 14 days any monies paid via banking transfer into your nominated account. Suspension and cancellation policy All membership options give you the ability to suspend your membership at no extra charge for a minimum of 2 weeks and up to a maximum of 1 month during your minimum term. We require 5 business days before your payment date to suspend your membership. If you cancel your membership within the minimum term there is an upfront 100% cancellation fee of your remaining payments, we require 14 business days before your payment date to cancel your membership. You can terminate the agreement due to sickness or physical incapacity at no extra charge, however, you must supply a medical certificate. 5 Hour cancellation Policy Should I cancel a personal training session with less than 5 business hours notice, I acknowledge that the session is forfeited and full - training fees applies. For Monday morning sessions I will leave a message on Sunday. When I give 5 hours notice I acknowledge that rescheduling my appointment to a more convenient time at no charge, will be pending on availability of training times. After Your minimum Term Your membership is ongoing after your minimum term (12 weeks) so no changes will be made unless you notify us via email. After your minimum term, you can suspend or cancel your membership with no cancellation fee by providing 14 days notice via email. Understand that I am entering into an agreement for a minimum term of 12 weeks during which i will be debited on a fortnightly basis for the selected service, as per the ezidebit agreement. I have read, understand Team Impaacts terms and conditions. Name* First Last Participant's Signature*Click To SignDate*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920WAIVERAcceptance of risk* I am aware that all activities associated with receiving group fitness personal training instruction from the trainer including, but not limited t activities involving aerobic exercise, stretching, running and weight lifting, as well as additional strenuous exercise and or exertion of strength, and other sustained physical activities which place stress on the cardiovascular and muscular system collectively referred to as "Training", are and can be hazardous activities that include certain risk and dangers, including but not limited to catastrophic injuries including paralysis, other serious injuries and death. I voluntarily accept full responsibility of all risks involved, including risks from participating in any way in the training, use of equipment provided by the trainer of use of equipment I provide, whether the training occurs at the park, gym, home, or any other location and in any weather condition. I have read the acceptance of risk provision in this agreement and I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am singing the agreement freely and voluntarily and intend, by my signature that this document is completed and an unconditional release of liability to the greatest extent allowed by law. The information given by me in this safety questionnaire is true, complete and accurate and I understand the advice given above. I have obtained clearance from a medical professional where required or recommended. Name* First Last Participant's Signature*Click To SignDate*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
