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Chicago Fit Performance Virtual Training
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Name
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First Name
Last Name
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Contact Number
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Area Code
Phone Number
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Email
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example@example.com
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4
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
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Fitness Safety Screen
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NO
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Do you feel pain in your chest when you perform physical activity?
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Fitness Safety Screen
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NO
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In the past month, have you had chest pain when you were not performing any physical activity?
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Fitness Safety Screen
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Do you lose your balance because of dizziness or do you ever lose consciousness?
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Fitness Safety Screen
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NO
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Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Fitness Safety Screen
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NO
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9
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Fitness Safety Screen
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NO
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10
Do you know of any other reason why you should not engage in physical activity?
Fitness Safety Screen
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NO
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11
Informed Consent for Virtual Fitness
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This Agreement is entered into between Chicago Fit Performance (“Studio”) and the undersigned (“Client”). The provision of group fitness training at 1535 N Dayton Street, Chicago IL, 60642 (“location”) by Studio to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement. ASSUMPTION OF RISK: I understand that the activities in this program may be strenuous, and may require me to do body movement that I may not be familiar with in order to improve overall fitness. I understand that I am responsible for monitoring my own condition throughout my workouts. Should any unusual symptoms occur, I will cease my participation and notify my healthcare provider. I know that there may be risks associated with the Fitness Program and willingly accept those possibilities. I know that it is my responsibility to ensure my own safety. I take full responsibility for my own health and safety in participating in the Fitness Program and to the extent I deem advisable, will consult a physician before participating in any of the activities. I freely and voluntarily agree to participate in the Fitness Program for my own personal benefit, and 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 the Fitness Program. I assume all risk for my health and well-being and hold harmless of any responsibility, the instructor, facility or any persons involved with the Fitness Program. I affirm that I have read, accept and understand this form in its entirety and that I understand the nature of exercise. RELEASE: You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Studio (and Studio’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Studio, whether active or passive, or any of Studio’s affiliates, employees, agents, representatives, successors, and assigns. This waiver and release of liability includes, without limitation, injuries which may occur as a result of: (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including personal training, (d) negligent hiring or retention of employees, and/or (e) slipping or tripping and falling while on any portion of a premises or while traveling to or from personal training, including injuries resulting from Studio’s or anyone else’s negligent inspection or maintenance of the facility or premises, (f) training you undertake that is online only without the supervision of a coach. The coach will provide step by step instruction on completing the exercise in a safe manner but cannot monitor you while you are completing these exercises. If you are unable to complete the exercise due to physical limitation or lack of understanding DO NOT attempt. If you do attempt, you will be liable for any injury sustained. ACKNOWLEDGMENTS: You expressly agree that the foregoing release, waiver, assumption of risk agreement is intended to be as broad and inclusive as permitted by the law in the State of Illinois and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk. You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against Studio or Studio’s negligence, or for any defective product used while receiving personal training from Studio. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.
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12
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