Group Fitness Class Registration

Include Name, Relationship & Contact Info

If participating in classes with your child.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you perform physical activity?

Have you had chest pain when you were not doing physical activity?

Do you lose your balance due to dizziness or do you ever lose consciousness?

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.)?

Are you pregnant now or have given birth within the last 6 months?

Have you had a recent surgery?

Do you take any medications, either prescription or non-prescription, on a regular basis?

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.

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.