HealthStyle Fitness: Registration for Customized Small Group Training 2-week Trial

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	Registration for Membership

HealthStyle Fitness, Inc.
REGISTRATION for Essentials, Customized or 1-Month Trial Membership

Fill out the online form below to register. After submitting the registration form you will be directed to your payment page.
Payment Page: Pay via Paypal. Choose your set up (Essentials, Customized or Trial) to finish your online registration. A PayPal account is not required to pay via PayPal.

Registration Form
Upon completion of your registration you will be notified to schedule your consultation, evaluation and nutrition seminar.
Personal Information
Name
Address
City
State / ZIP	/
Profession
Country
Date of Birth	(mm/dd/yyyy)
Phone Number
Work Number
Fax Number
Email Address	Please provide an email address that you check regularly. We DO NOT share your information with anyone and fully respect your privacy, but do send important information via email.

Self Assessment & Additional Information
I rate my current fitness level as a (1-10), ten being high.
I was referred by:
How did you hear about us?:
Please specify publication / website / friend or other referral:
Is this the first time you've worked with us?:	Yes \| No
If you answered "no", when was the last time you worked with HealthStyle Fitness?
My Main goal is:
Name of Emergency Contact & Phone Number	\|

HSF and Payment Information
What Days & Times Are Convenient for Your Health, Fitness & Nutrition Analysis?
Form of payment:

Medical History
(If you are a returning client, only complete the sections that have changed.)
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
List Medications:
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
List Medications:
3. Do you have a seizure disorder (epilepsy)?
4. Do you have diabetes Adult or Juvenile?
List Medications:
5. Have you ever been found to be anemic (low blood count)?
6. Do you have High Blood Pressure (hypertension)?
List Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease:
Lung Disease:
Kidney Disease:
Liver Disease:
8. Do you have asthma?
List Medications:
9. Have you ever had a severe neck injury? Describe:
10. Have you ever been knocked out? Describe:
11. Do you wear glasses or contact lenses?
12. Have you had a broken bone or fracture in the past 2 years? Describe:
13. Have you ever injured your back? Describe:
14. Do you have back pain?
15. Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe:
16. Do you have other physical conditions which cause pain? Describe:
17. Detail any surgical procedures:
18. What are your goals for the next three months?
19. Have you had your body fat tested?
If yes, what percent is it?
20. What is your ultimate health and fitness goal?

Release
NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program. This release is entered into between the undersigned and HealthStyle Fitness, Inc., its officers, subsidiaries, affiliates, and executors in addition to the City of Cincinnati. The purpose of HealthStyle Fitness, Inc. is to provide fitness instruction and coaching for various levels of athletes/individuals. The undersigned hereby acknowledge that the following was explained to me and/or agree to the following: 1. Acknowledges that Brian Calkins, or any member of his staff, is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice. 2. Acknowledges that the undersigned has been told if they feel tired, feel pain or feel out of the ordinary in any way either related to your training, or otherwise, that the undersigned should contact a physician at once. 4. Acknowledges that the HealthStyle Fitness, its programs require physical exertion. The undersigned assumes the risks of participating in exertion activities, and they have a regular medical physician they can contact regarding any medical problems that they might develop. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind HealthStyle Fitness, Inc., Brian Calkins, or any member of his staff, for the undersigned participating in said sporting events and/or training for said sporting events. The Undersigned agrees that this is the full agreement between the parties, that HealthStyle Fitness, Inc, including Brian Calkins, his staff, nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion.
Checkmark the following:
	I agree to show up at HealthStyle Fitness expecting to have a great workout, and leave feeling Energized and ready to tackle the day!
	I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of working with HealthStyle Fitness, Inc.
	I agree to show up for HealthStyle Fitness and workout as often as I can since I have UNLIMITED workout sessions with a highly professional trainer.
	I understand that overtime exercise may become a positive addiction, and it will help me be more productive and happy.
	I understand that when I show up to HealthStyle Fitness, the staff will be excited to see me.
	I will remember to be in the studio on time.
	I understand that diet and nutrition will effect my fitness goals and performance.
	I will bring a positive attitude, and expect to have fun and get into shape.

Agreement and Signature

I agree to all Terms and Conditions listed above

Electronic Signature

Date (MM/DD/YYYY)

© 1999 - 2012 HealthStyle Fitness, Inc, Cincinnati Personal Training, Cincinnati Nutrition & Brian Calkins - Cincinnati, Ohio
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