I understand that I will be participating in a fitness program through customFIT™ and/or 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 or customFIT™ 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, Bekah Self, LLC, or customFIT™ 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 or customFIT™. 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.
Are you under the care of a physician, chiropractor, or other health care professional for any reason?
If yes, please list reason.
Do you have a family history of cardiovascular disease?
If so, how many occurrences and what approximate ages?
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
Please list the foods, beverages, supplements, etc. that you take on the average day.
Time / Quantity / Food-Beverage Supplement
Please list any foods that you must restrict for any reason.
(i.e. medical, allergy, etc.)
Have you ever been told to follow a specific nutritional plan in the past?
If so, please indicate the reason, type of plan and who provided it to you.