Name
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First Name
Last Name
Email Address
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Phone
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Date of Birth
MM
DD
YYYY
What is your age?
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
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Participant's Signature
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I understand that I will be participating in a fitness program through Bekah Self, LLC (the “Program”). The Program may consist of personal training, small group training or large group training that will require physical exertion. I neither have physical limitations nor am I taking any medications or receiving any medical treatment that might make it unsafe for me to participate in the Program. I understand that, by signing this statement, I am agreeing to not hold Bekah Self, LLC responsible for any bodily injury or property damage that I may suffer as a result of my participation in the Program. As such, I understand and agree that neither Bekah Self, personally, or Bekah Self, LLC shall be liable for any bodily injury or property damage that may result either directly or indirectly from my participation in the Program through Bekah Self, individually or personally, Bekah Self, LLC I understand, acknowledge and agree to the above waiver. I understand I have the right to have an attorney review this waiver before signing it.
customFIT Program
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Please select the program or programs you are interested in. (You are not locked into this program until payment has been made.)
What is the best time of day that works for you to train/workout?
I'm interested in trying out the FREE Online Fitness Classes!
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We are a small and growing community of women committed to growing physically and spiritually! MWF 9:00am-9:45am CST
How did you hear about customFIT or Trainer Bekah Self?
Are you under the care of a physician, chiropractor, or other health care professional for any reason?
If yes, please list reason.
Are you aware of any disease or disorder that would complicate your participation in a exercise program?
Please explain your current exercise regimen including all strength training, cardiovascular training or other sporting activities that you perform.
Day of the Week / Activity / Length of Time
What are your goals?
(Check all that apply.)
How active are you?
Please check all statements that are true for you.
I agree to pay for the entire 4 consecutive week, 8 consecutive week or 12 consecutive week commitment at the agreed upon rate.
