Waiver

Client Details

*

Name * Nick Name *

Date of Birth*

Sex*

Male
Female

Address*

Address Line Address Line 2 City State/Province/Region Zip/Postal Code Country

Occupation*

Email*

Mobile*

Phone Number *

Emergency Contact*

Emergency Contact Name

Emergency Mobile*

Emergency Contact Name

How 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 History

I am*

New To Exercise
Somewhere In The Middle
Experience

Currently Exercising?*

Yes
No

Times Per Week?*

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 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 PRIORITIES

Weight Loss

Loss Weight
Shape and Tone
Reduce body Fat
Decrease Clothing Size

Would 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

Why do you want to achieve these results?*

When do you want to achieve these by?*

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*

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 Sign

Date*

Acceptance 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 Sign

Date*