Authentic Strength Training (Authentic Strength Camp)
I __________________________________ have agreed to participate in Authentic Strength Training’s fitness service, an indoor and outdoor fitness camp. The activities of Authentic Strength Camp include strength training, running, agility drills, jumping, intense cardiovascular activities and flexibility training. Acknowledgment is hereby made that the activities of the camp will require me to spend time outside in the heat, as well as inside. I further acknowledge that there are risks involved in participating in the strength camp. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, my physical condition, equipment, actions of other people including, but not limited to,
participants, volunteers, and lack of hydration.
In consideration of my being accepted into the program, I agree to release and discharge Authentic Strength Training and any of its employees, volunteers, coaches and supervisors, The City Of Santa Fe Springs, Authentic Strength Camp’s, Tony Falaro, owner of the facilities, from any injuries sustained by me as a result of participation in this program. I agree to indemnify and hold harmless, Authentic Strength Training, and any of its employees, volunteers and supervisors, facilities and owners of the facilities against any liability incurred as a result of such injury or loss. Fitness activities and programs require that I be in good health and have no condition that could endanger my well being through participation. I will notify Authentic Strength Training of any such defects in writing prior to enrolling in this program.
The undersigned agrees to save and hold harmless and indemnify
each and all of the parties referred to above from all liability, loss,
cost, claim or damage whatsoever which may be imposed upon said
parties because of any defect in or lack of such capacity to so
act and release said parties on behalf of myself.
Signature of participant__________________________________________
Parent if under 18 yrs old________________________________________
Date_______________
Name______________________________
Address____________________________
Your Phone___________________________
City / State, Zip______________________
Occupation__________________________
E-Mail _________________________________
DOB___________________________________
Emergency Contact________________________ Their Phone __________________
1. Medical History and Present Medical Condition
Check any of the conditions described below which you have, or have had in the past.
? Coronary Heart Disease ? Fractures or Broken Bones
? Diabetes (Type 1 or 2) ? Cold Hands or Feet
? Stroke ? Light-headedness or Fainting
? Peripheral Vascular Disease ? Epilepsy or Seizures
? Phlebitis or Emboli ? Anemia
? Rheumatic Fever ? Asthma
? High Blood Pressure ? Emphysema
? Low Blood Pressure ? Bronchitis
? Chest Pain or Discomfort ? Pneumonia
? Heart Murmur ? Ulcers
? Ankle Swellings ? Hernia
? Migraines ? Arthritis
? Swollen, Stiff, or Painful Joints ? Bursitis
? Foot Problems ? Stomach or Intestinal Problems
? Back Problems ? Osteoporosis
? Neck Problems ? Allergies
If you checked any of the above, please explain here.
List any prescribed medications you are taking.
List any over the counter medications or dietary supplements that you are taking.
List any illnesses, hospitalizations, or surgical procedures within the past 2 years.
2. Health and Fitness History
If you were involved in exercise or sports in the past, please describe the activity, its
intensity and duration.
How would you describe yourself today? (Circle one)
Sedentary/Inactive Lightly Active Moderately active Highly Active
How would you describe your nutrition habits? (Circle one)
Poor Fair Good Excellent
Describe your knowledge of exercise and fitness. (Circle one)
Poor Fair Good Excellent
Describe you knowledge of nutrition. (Circle one)
Poor Fair Good Excellent
Do you consume alcohol? ? Yes ? No
If you checked yes, how much do you consume?
Do you currently smoke, or have you ever smoked? ? Yes ? No
If you previously smoked, how long did you smoke, how often, and when did you quit?
If you currently smoke, how often and how much do you smoke?
Do you consider yourself underweight or overweight? (Circle one)
How many meals do you have each day?
3. Fitness Goals and Objectives
Check any of the fitness goals described below which you wish to achieve.
? Improve Strength ? Reduce Stress
? Improve Flexibility ? Increase Strength
? Improve Cardiovascular Fitness ? Stop Smoking/drinking
? Improve Muscle Tone and Shape ? Injury Prevention
? Improve Diet/Eating Habits ? Rehabilitate Injury
? Lose Weight ? Gain Weight/Muscle
? Improve Muscular Endurance
What is your main purpose for applying to Authentic Strength Training? (please be very clear)
Are there any other final comments you may wish to add to this questionnaire?
I hereby state that I have, to the best of my knowledge, given an accurate report on my
medical, fitness, and health history.
Signature __________________________________________
Date____________
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