REGISTRATION FORM
Personal Information
Full Name:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
Home Phone:
State
(
Alternate
Phone:
)
(
ZIP Code
)
E-mail Address:
Gender: Male or Female
Birth date:
Age:
Job Information
Title:
Employer:
Emergency Contact Information
Full Name:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
Primary Phone:
State
(
)
Alternate Phone:
(
)
Relationship:
Primary Care
Physician:
Phone:
Session Information
Cost:
Rock Star package deals: 1 free V.I.P session
Sign-up
$ 180
Renewals
$ 100 automated draft $79
Added value:
Homework
Nutritional plan
Special Inclusion to Community Partnership events
ZIP Code
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE
1. HAS A DOCTOR EVER SUGGESTED YOU HAVE A HEART CONDITION AND RECOMMENDED ONLY
MEDICALLY SUPERVISED PHYSICAL ACTIVITY? _________
2. DO YOU FREQUENTLY SUFFER FROM CHEST PAIN? _________
3. DO YOU TEND TO LOSE CONSCIOUSNESS OR FALL OVER AS A RESULT OF DIZZINESS? _________
4. HAS A DOCTOR RECOMMENDED MEDICATION FOR YOUR BLOOD PRESSURE OR A HEART
CONDITION? _________
5. DO YOU HAVE A BONE OR JOINT PROBLEM THAT COULD BE AGGRAVATED BY THE PROPOSED
PHYSICAL ACTIVITY? _________
6. ARE YOU AWARE THROUGH YOUR OWN EXPERIENCE OR A DOCTOR’S ADVICE OF ANY OTHER
PHYSICAL REASON AGAINST YOU EXERCISING WITHOUT MEDICAL SUPERVISION? _________
MEDICAL HISTORY
CONDITIONS
YES
NO
EXPLANATION
HEART CONDITION
HIGH BLOOD PRESSURE
ANGINA
ASTHMA
SHORTNESS OF BREATH
ULCER
OSTEOPOROSIS
ARTHRITIS
RHEUMATISM
HERNIA
SACROILIAC BURSITIS
RECENT SURGERY
DEPRESSION
PSYCHOLOGICAL PROBLEMS
KNEE PROBLEMS
BACK PROBLEMS
Other medical problems: __________________________________________________________________________________________
I certify that the above statements are true and correct:
Client Signature: ___________________________________________
Date: ______________________
GOAL ASSESMENT QUESTIONNAIRE
Goals: __________________________
Are you currently doing any type of cardiovascular exercise? YES / NO
If yes, type: __________________ Duration: _________________ Frequency: _____________________
Have you ever participated in any type of resistance training? YES / NO
If yes, type: _______________________
How many days per week would you like to train? _____________
Have you ever trained with a fitness trainer before? YES / NO
What would you like to change or improve about your physique and overall well being?
___________________________________________________________________________________
Do you have a time frame in mind for achieving these goals? ________________________________
How committed are you to achieving your goals? Low 1 2 3 4 5 6 7 8 9 10 High Priority
VITAL STATISTICS AND CIRCUMFERENCE MEASUREMENTS
Initial Evaluation 2nd Evaluation
Height:
Date:
Age:
Bodyweight:
Resting Heart Rate:
Training Heart Rate:
Body Fat %
Neck:
Chest:
Biceps:
Bicep: RT / LT
Waist:
Hips:
Quad: RT / LT
Calf: RT / LT
Push up assessment
Squat assessment
Crunch assessment
Goal
WAIVER FORM
INFORMED CONSENT
I, ___________________________, VOLUNTARILY CONSENT TO ENGAGE IN A FITNESS ASSESSMENT, EXERCISE TEST, AND
FITNESS TRAINING. I UNDERSTAND THAT THE CARDIOVASCULAR FITNESS TEST WILL INVOLVE PROGRESSIVE STAGES OF
INCREASING EFFORT AND THAT AT ANYTIME; I MAY TERMINATE THE TEST FOR ANY REASON. I UNDERSTAND THAT DURING
SOME TEST I MAY BE ENCOURAGED TO WORK MAXIMUM EFFORT, AND THAT AT ANYTIME, I MAY TERMINATE THE TEST FOR
ANY REASON. THE REACTION OF THE CARDIOVASCULAR SYSTEM TO AEROBIC OR WEIGHT LIFTING ACTIVITIES CANNOT
ALWAYS BE PREDICTED WITH COMPLETE ACCURACY. I UNDERSTAND CERTAIN PHYSICAL CHANGES MAY OCCUR DURING THE
EXERCISE TEST AND SUBSEQUENT EXERCISE ACTIVITIES. SUCH CHANGES INCLUDE BUT ARE NOT LIMITED TO ABNORMAL
BLOOD PRESSURE, FAINTING, DISORDERS OR THE HEART RATE, AND VARY IN RARE INSTANCES OF HEART ATTACK OR CARDIAC
ARREST. I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO MINIMIZE PROBLEMS FOR MONITORING MY OWN CONDITION
THROUGH THE PROCEDURES AND SHOULD ANY UNUSUAL SYMPTOMS OCCUR, ALL CURRENT ACTIVITY SHALL DESIST
PARTICIPATION AND INFORM THE TEST ADMINISTRATOR AND OR PERSONAL TRAINER OF THE SYMPTOMS. SUCH SYMPTOMS
COULD INCLUDE BUT ARE NOT LIMITED TO: NAUSEA, DIFFICULTY BREATHING, CHEST DISCOMFORT, JOINT OR MUSCLE INJURY.
I ALSO UNDERSTAND THAT AN EMERGENCY PROTOCOL HAS BEEN PLANNED. IN THE EVENT OF AN EMERGENCY SITUATION, I
AM FINANCIALLY RESPONSIBLE FOR ANY AND ALL EMERGENCY SERVICES THAT MAY BE NECESSARY.
I AGREE TO ASSUME ALL RISK OF THE FITNESS TESTING AND FITNESS TRAINING, I HERE BY RELEASE, AND HOLD HARMLESS,
“ROCKSTAR FITNESS CAMPS” AND THERE AGENTS AND EMPLOYEES FROM ANY AND ALL HEALTH CLAIMS, SUITS, LOSSES, OR
CAUSES OF ACTION FOR DAMAGES, INJURY OR DEATH, INCLUDING CLAIMS FOR NEGLIGENCE, ARISING OUT OF OR RELATED TO
MY PARTICIPATION IN THE FITNESS ASSESSMENTS AND TRAINING.
I HAVE READ THE FORGOING CAREFULLY AND COMPLETELY AND I UNDERSTAND ITS CONTENT. ANY QUESTIONS THAT MAY
HAVE OCCURRED TO ME CONCERNING THIS INFORMED CONSENT HAVE BEEN ANSWERED TO MY SATISFACTION.
_________________________________________
Client’s Signature of Agreement
________________________________________
Authorized (RockStar Fitness Employee)
________________________
Date
________________________
Date