Your Live Trainers - Silver Member - Health History and Liability Waiver Form

Health History and Liability Waiver Form

Attention: Fill out contact information and medical history/PAR-Q (This information will be kept confidential)

*This form must be completed in order to sign up for your membership package.

* - required fields

Personal Information

*First Name: *Last Name:

*Street Address: *Unit or Apartment:

*City: *State: *Zip Code:

*Day Phone: *Evening Phone:

*Email Address (must have email in order to train):

*Age: *Sex: *Birthday: : : *Height: *Weight:

Buddy

*Buddy Name (if applicable): *Buddy Last Name:

*Buddy Email (if applicable):

Physician Information

*Physician's First Name: *Physician's Last Name:

*Physician's Address: *Unit/Suite:

*City: *State: *zip:

*Physicians Phone: *Physicians Fax:

Your Schedule

Which days and times are normally best for you?

*Day: *Time: : :