Which Workshop Are You Registering For? * Mash-Up Fitness - Instructor & Trainer Workshop Name * First Last Email * Phone * Address * Street Address Address Line 2 City State / Province / Region Zip / Postal Code Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Country Date Of Birth * Age * Emergency Contacts *
Include Name, Relationship & Contact Info
Please mark YES or NO to the following:
Heart Condition *
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Chest Pain During Activity *
Do you feel pain in your chest when you perform physical activity?
Chest Pain Without Activity *
Have you had chest pain when you were not doing physical activity?
Balance & Losing Consciousness *
Do you lose your balance due to dizziness or do you ever lose consciousness?
Health Issues *
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, rnanorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
Pre & Post-Natal *
Are you pregnant now or have given birth within the last 6 months?
Recent Surgery *
Have you had a recent surgery?
If you marked YES to any of the above, please elaborate below: How did you hear about CareerFit Mom? * Would you like to receive my email newsletter with news of upcoming workshops, tips and promotions? * PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT *
I wish to participate in the exercise and training program offered by CareerFit Mom (CFM). I understand there are inherent risks in participating in a program of strenuous exercise and I do so strictly at my own risk. I further agree that CFM, Beth Yarzab and/or any fitness professional working with CFM shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program. I expressly release and discharge CFM, its owners, employees, agents and/or assigns from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by an intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.
I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during the workshop. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform CFM or alternate staff.
I understand that CFM may photograph and/or video tape workshop events/sessions and I provide CFM the absolute right and permission to use these pictures/images for any lawful promotional, advertising or marketing purpose.
Indicate agreement by typing your Full Name *
I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.