Registration: Gravity Express | Cincinnati's Fitness Program that Produces Results

Gravity Fitness Program
REGISTRATION

You now have 2 options:
A. You can print this form and send it in with payment by mail
B. Register Online
Fill out the online form below to register via internet. Click on Submit to go to the payment page.
Payment Page: Pay via Paypal. Choose your class and finish your online registration. A PayPal account is not required to pay via PayPal.

NOTE: Spaces fill quickly for personal training. We cannot guarantee your space until we have received payment.

If paying by check, please make check out to:

HealthStyle Fitness, Inc.
4325-B Red Bank Road
Cincinnati, Ohio 45227
Email HealthStyle Fitness!
Phone: (513) 407-4665

If you choose option A, Print this page and mail it in with payment.
If you choose option B: Fill out the form below and Click on SUBMIT.

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

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:
This is my first Gravity Program:	Yes \| No
If you answered "no", when was the last Gravity Program you attended:
My Main goal is:
Name of Emergency Contact & Phone Number	\|

Gravity Program and Payment Information
What Gravity Program are you joining?
Choose How Long Would You'd Like to Register? Monthly Payment Plans are Available.
Form of payment:
$299 (1-Month – Meets 13 times - $25 per session) $269/month (3-Months – Meets 39 times – 10% Savings per month) $239/month (6-Months – Meets 78 times - 20% Savings per month)

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. Are you training for a specific event? If yes, explain:

Release
NOTICE: It is wise to seek your doctor’s 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 the Gravity Program is to provide fitness instruction, training 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 Gravity Program, TFM, boot camps, aerobic classes, martial arts, kick boxing, running, kung-fu, weight training, obstacle courses, and any other related sports are an extreme test of one's mental and physical limits and carry with it potential for damage or loss of property, serious injury and death. That the undersigned assumes the risks of participating in these types of events/activities including the elements of a natural environment, that they are fit, 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 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. Customer/client agrees to confidentiality with respect to the Gravity Program and all services provided by HealthStyle Fitness, Inc. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of the Gravity Program. The undersigned agrees to a non-compete within a 50 mile radius of Cincinnati for a period of 5 years from date of participation
Checkmark the following:
	I agree not to use foul language during the Gravity Program. Any violation will result in twenty push-ups on a stability ball per occurrence.
	I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of the Gravity Program. Any violation will result in the Wheel Barrel Walk for 100 yards, per occurrence.
	I agree to show up for every Gravity session that I am registered for unless it is an excused absence from my doctor.
	I understand that photos or video may be taken during the course of my involvement in the Gravity Program, which may be used for promotional purposes. I understand that my "before & after" photos will not be used for any promotional purposes unless I give written authorization.
	I understand there is no refund policy, but I can receive a credit (for unused portion of the Gravity Program) towards a future Gravity Program group if I'm not able to complete the one I originally joined. Fees cannot be used towards any other products or services provided by HealthStyle Fitness, INC.
	I will remember to be in the studio on time.
	I understand that diet and nutrition will affect my fitness goals and performance during the Gravity Program.
	I will bring a positive attitude, and expect to have fun.

Agreement and Signature

I agree to all Terms and Conditions listed above

Electronic Signature

Date (MM/DD/YYYY)

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