Client 360 - Health History Overview

Please choose a name of Flex5 Coach these forms are for.
Name *
Name
Phone *
Phone
Date of Birth *
Date of Birth
Country (if outside of US). State/City (if within US)
Please provide spouse's/partner's name if applicable
Please list their names if applicable
Please provide their names if applicable
We would like to celebrate these with you!
What are your ideal appointment days? *
Please select your ideal appointment days
What are your ideal appointment times? *
Please select your ideal appointment times



BOOT CAMP WAIVER

Name *
Name
Date of Birth *
Date of Birth
Phone *
Phone
Physical Activity Readiness Questionnaire (PAR-Q)
Only check off if the answer is "Yes" and explain in the additional comments section.
Exerciser hereby stipulates that he/she is physically sound and that he/she has approval to proceed with a routine of exercise. I (the undersigned) have agreed to participate in the PetroFitness, LLC Conditioning Boot Camp Program. I recognize that the program involves strenuous physical activity including, but not limited to, strength training, running, agility drills, jumping, intense cardiovascular activities and flexibility training. I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition, which would prevent or limit my participation in this exercise program. I acknowledge that my registration and subsequent participation in the PetroFitness, LLC Conditioning Boot Camp Program is completely voluntary. It is further expressly agreed that all strength training, cardiovascular exercise, or any other exercise shall be undertaken by me at my sole risk and that PetroFitness, LLC, Flex5, Petro Martynyuk and his agents or employees shall not be liable to me for claims, demands, injuries, damages, actions or causes of action, whatsoever, to my person or property arising out of or connected with the use by me of the services provided and of the premises where the same is located. I do hereby expressly forever release and discharge PetroFitness, LLC, Flex5, Petro Martynyuk and his agents or employees from all such claims, demands, injuries, damages, actions or causes of action, from all acts of active or passive negligence on the part of PetroFitness, LLC, Flex5, Petro Martynyuk and his agents or employees. I further expressly agree that I will not use equipment improperly. If I have any questions whatsoever, concerning exercise and use of equipment, I agree that I will request instruction from Petro Martynyuk and or his agents or employees. DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND THE TERMS COMPLETELY. IF YOU DO NOT UNDERSTAND, YOU SHOULD SEEK LEGAL COUNSEL.
Today's Date *
Today's Date



PERSONAL TRAINING AGREEMENT

Client Name *
Client Name
Phone *
Phone
1. I have made my trainer aware of my objectives and goals. 2. I understand my trainer will arrive on time, prepared for the workout and act in a professional manner in the commitment to help me achieve my fitness goal. If the trainer is more than 5 minutes late for a session then the session or a future session will be complimentary. 3. I understand that there is a 24-hour cancellation policy and cancellations that occur after that time will be termed a “short call”. I will receive one short call per 10 sessions without penalty. Any short calls thereafter will be charged as a full session. 4. I understand these guidelines are in place to provide professional service between the individual and the personal trainer, and to ensure accountability on both sides and increase the probability of a successful program. 5. I understand that it is the policy of Flex5 that personal training sessions are nonrefundable. 6. I understand that the personal training sessions I am purchasing with this contract will expire in six (6) months.
Date *
Date

HEALTH COACHING AGREEMENT

Dear Participant,

Welcome. During the coming six months, you will learn ways to help yourself achieve a healthier diet and lifestyle. Please read the following and ask questions if there is anything unclear.

This Agreement is made today between the Coach of the Program and the person named at the end of this document. The Program in which you are about to enroll in will include all of the following:

SCHEDULING

As your Coach, I understand that my clients have busy schedules and I take pride in not keeping them waiting or keeping them longer than planned. Each session will end 60 minutes after it was scheduled to begin. Please be on time. If the Client needs to cancel or reschedule the appointment, the Client must do so 24 hours in advance; otherwise, the Client will forfeit that appointment and will not have an opportunity to reschedule it.

PAYMENTS AND REFUNDS

The Client understands that the regular cost of the Program is $999. Payment of $999 is due on the first meeting and may be made by credit card or check. If the Client selects to pay the full cost of the program today, the cost shall be reduced by another $250 (for a total cost of $749).

In the event of the Client’s absence or withdrawal, for any reason whatsoever, the Client will remain responsible for the pro-rata share of the program that has been delivered, plus a cancellation fee of $50.00.

The Coach reserves the right to cancel the program if at any point she or he feels it is not advantageous for the coaching program to continue. If this happens, the Client is only responsible for the pro-rata share of coaching services received.

DISCLAIMERS

The Client understands that the role of the Health Coach is not to prescribe or assess micro- and macro-nutrient levels; provide health care, medical or nutrition therapy services; or to diagnose, treat or cure any disease, condition or other physical or mental ailment of the human body.  Rather, the Coach is a mentor and guide who has been trained in holistic health coaching to help clients reach their own health goals by helping clients devise and implement positive, sustainable lifestyle changes. The Client understands that the Coach is not acting in the capacity of a doctor, licensed dietitian-nutritionist, psychologist or other licensed or registered professional, and that any advice given by the Coach is not meant to take the place of advice by these professionals.  If the Client is under the care of a health care professional or currently uses prescription medications, the Client should discuss any dietary changes or potential dietary supplements use with his or her doctor, and should not discontinue any prescription medications without first consulting his or her doctor. 

The Client has chosen to work with the Coach and understands that the information received should not be seen as medical or nursing advice and is not meant to take the place of seeing licensed health professionals.

PERSONAL RESPONSIBILITY AND RELEASE OF HEALTH CARE RELATED CLAIMS

The Client acknowledges that the Client takes full responsibility for the Client’s life and well-being, as well as the lives and well-being of the Client’s family and children (where applicable), and all decisions made during and after this program. 

The Client expressly assumes the risks of the Program, including the risks of trying new foods or supplements, and the risks inherent in making lifestyle changes. The Client releases the Coach from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the Client ever had, now has or will have in the future against the Coach, arising from the Client’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Coach.

CONFIDENTIALITY

The Coach will keep the Client’s information private, and will not share the Client’s information to any third party unless compelled to by law.

ARBITRATION, CHOICE OF LAW, AND LIMITED REMEDIES

In the event that there ever arises a dispute between Coach and Client with respect to the services provided pursuant to this agreement or otherwise pertaining to the relationship between the parties, the parties agree to submit to binding arbitration before the American Arbitration Association (Commercial Arbitration and Mediation Center for the Americas Mediation and Arbitration Rules). Any judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Such arbitration shall be conducted by a single arbitrator. The sole remedy that can be awarded to the Client in the event that an award is granted in arbitration is refund of the Program Fee. Without limiting the generality of the foregoing, no award of consequential or other damages, unless specifically set forth herein, may be granted to the Client.

This agreement shall be construed according to the laws of the State of North Carolina. In the event that any provision of this Agreement is deemed unenforceable, the remaining portions of the Agreement shall be severed and remain in full force.  

If the terms of this Agreement are acceptable, please sign the acceptance below. By doing so, the Client acknowledges that: (1) he/she has received a copy of this letter agreement; (2) he/she has had an opportunity to discuss the contents with the Coach and, if desired, to have it reviewed by an attorney; and (3) the client understands, accepts and agrees to abide by the terms hereof. 

Date *
Date

FLEX5 PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) WITH
 WAIVER AND RELEASE OF LIABILITY

PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people, physical activity should not pose any problems or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these few questions. Please read the carefully and check YES or NO opposite the question if it applies to you. If yes, please explain.

Please choose Flex5 Coach Name these forms are for.
CLIENT NAME *
CLIENT NAME
DATE OF BIRTH *
DATE OF BIRTH
CONTACT PHONE NUMBER *
CONTACT PHONE NUMBER
EMERGENCY CONTACT NUMBER
EMERGENCY CONTACT NUMBER
Physical Activity Readiness Questionnaire (PAR-Q)
If you answer NO to all questions below (by not selecting any of the choices), it gives a general indication that you may participate in physical and aerobic fitness activities and/or fitness evaluation testing. The fact that you answered NO to the above questions, is no guarantee that you will have a normal response to exercise. If you answer YES to any of the below questions, then you may need written permission from a physician before participating in physical and aerobic fitness activities and/or fitness evaluation testing at PETRO FITNESS, LLC.
WAIVER AND RELEASE OF LIABILITY
TODAY'S DATE *
TODAY'S DATE


Meal Prep Intake Form

Name *
Name
Phone *
Phone
Date of Birth *
Date of Birth
Upon signing this waiver, you are confirming the information you have provided is true and have answered each of these to the best of your ability. Furthermore, upon signing this waiver, you are solely responsible for providing our Chef with any dietary restrictions, allergies, as well ANY food related reactions you have had in the past 12 months. Flex5 Fitness and Wellness are not, and cannot be held responsible for any reactions, illness, or distain from our service that have not been included within this waiver. You are responsible for proper Food Safety Handling procedures after the Meal Service takes place, forfeiting responsibility from Flex5 Fitness and Wellness from any Food Born Illness that can occur from improper handling of 'ready to eat foods'.
Upon signing this waiver, you are confirming the information you have provided is true and have answered each of these to the best of your ability. Furthermore, upon signing this waiver, you are solely responsible for providing our Chef with any dietary restrictions, allergies, as well ANY food related reactions you have had in the past 12 months. Flex5 Fitness and Wellness are not, and cannot be held responsible for any reactions, illness, or distain from our service that have not been included within this waiver. You are responsible for proper Food Safety Handling procedures after the Meal Service takes place, forfeiting responsibility from Flex5 Fitness and Wellness from any Food Born Illness that can occur from improper handling of 'ready to eat foods'.



All-Inclusive Holistic Fitness & Wellness Center in Uptown Charlotte.
Address :
428 E 4th Street, Suite 333, Charlottel, NC 28202 Email : href="mailto:info@flex5clt.com">info@flex5clt.com