Which Class(es) Are You Registering For? * Stroller GroupFit (Mon. 10:30 am) Tabata Training (Mon. 7:35 pm) Wake Up GroupFit (Tues. 6:15 am) Outdoor GroupFit (Tues. 7:30 pm) Stroller GroupFit (Wed. 3:00 pm) Wake Up GroupFit (Thurs. 6:15 am) Outdoor GroupFit (Thurs. 1:15 pm) Tabata Training (Sat. 7:35 am) Running Clinic (Sat. 9:00 am) Free Run Club (Sun. 8:00 am) Multiple Classes (indicate below) Please type in which classes you are interested in attending. 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
Physician's Name & Phone Number * Child's Age & Name
If participating in classes with your child.
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: Medications *
Do you take any medications, either prescription or non-prescription, on a regular basis?
What is the medication for? How does this medication affect your ability to exercise or achieve your fitness goals? What are your fitness goals? What do you hope to achieve from this GroupFit class? * Please check all activities that interest you: How did you hear about CareerFit Mom? * Would you like to receive my email newsletter full of tips, promotions, special offers and more? * 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; consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. If I choose not to see a physician prior to beginning a fitness program, I do so strictly at my own risk and against recommendation of CFM. I also agree to provide CFM with my physician’s contact information so that CFM may receive direct clearance and program recommendation/limitations from my physician. 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 (whether at home, in a training studio, outdoors, or at a corporate, commercial, residential or other fitness facility), and 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 certify that the answers to the questions outlined on the PAR-Q form are true and complete to the best of my knowledge. I acknowledge that medical clearance is requested if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform CFM of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.
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 my training sessions. 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 the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.
I understand that during a fitness class, my trainer/instructor may have to touch my muscles or joints to correct alignment and/or to focus my concentration on a particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with this form of touch, I will immediately request that it be discontinued.
I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by CFM.
I understand that CFM or members of the media may photograph/video client 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.