This form is required for all participants and clients who participate in any fitness program through customFIT.

**Not all answers are required, but in order to best assist you in the development of a rewarding physical fitness program, I would appreciate you answer as many questions as you can with honest and accurate responses.

Name *
Phone *
Date of Birth
Date of Birth
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Number *
Emergency Contact Number
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.
customFIT Program *
Please select the program or programs you are interested in. (You are not locked into this program until payment has been made.)
FYI: The tank top is a long, slimming fit. Tank Tops are $25.00 each
Please list ages of child or children needing childcare.
If yes, please list reason.
If so, how many occurrences and what approximate ages?
Day of the Week / Activity / Length of Time
What are your goals?
(Check those that apply.)
How active are you?
Please check all statements that are true for you.
Time / Quantity / Food-Beverage Supplement
(i.e. medical, allergy, etc.)
If so, please indicate the reason, type of plan and who provided it to you.
I agree to pay for the entire 4 consecutive week, 8 consecutive week or 12 consecutive week commitment at the agreed upon rate.