BACK ON TRACK REGISTRATION Participant InformationParticipant Name(Required) First Last Participant Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Participant Cell Number(Required)Participant's Gender Participant's Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Email Address(Required) Emergency Contact Name(Required) First Last Emergency Contact Relationship(Required) Emergency Contact Phone(Required)Par-Q and Medical HistoryPhysical Activity Readiness Questionnaire1. Has a doctor ever said you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No 2. Do you feel pain in your chest when performing physical activity? Yes No 3. In the past month, have you had chest pain when NOT performing physical activity? Yes No 4. Do you lose balance because of dizziness or do you ever lose consciousness? Yes No 5. Do you have a bone or joint problem that could be made worse by a change in your/his/her physical activity? Yes No 6. Is your doctor currently prescribing any medication for blood pressure or a heart condition? Yes No 7. Do you know of any reason why you should not engage in physical activity? Yes No 8. Has a medical doctor ever diagnosed you with a chronic disease? If yes, please explain.WaiverI understand that I am purchasing online training sessions for myself and must read, agree to and sign this agreement where I assume the risks for participation, waive of liability, and agree to the Total Strength Fitness policies and procedures. I understand that the program is voluntary and that a Certified Personal Trainer/Running Coach will lead the training which includes high intensity exercises including weight lifting, plyometrics, and running. I represent that I will complete the PAR-Q and any other health history form accurately and completely including disclosure of any exercise limitations I am aware of or have been informed of by my doctor. During the program if my condition or medical limitations should change, I will notify the Trainer. I understand that it is recommended that I have a yearly physical or more frequent physical examination and consultation with my physician as to physical activity and diet so I am aware of what is appropriate for me. I acknowledge that I have had a physical exam and have been given a physician’s permission to participate, or I have decided to allow myself to participate without approval of a physician. I understand that a Trainer will review my PAR-Q and any other health history form but that a Trainer is not a physician and cannot replace the advice and expertise of a qualified physician. I understand that I have the complete right to stop or decrease my exercise at any time during a session and that it is my obligation to inform the Trainer of any symptoms such as fatigue, shortness of breath or chest discomfort. I realize that participation in an exercise training program includes but is not limited to exercising, use of exercise equipment and strenuous exertion (such as strength training or high intensity aerobic activity) which will increase heart rate and body temperature. I understand that exercise involves certain risks, including but not limited to, serious neck and spinal injuries resulting in complete or partial paralysis, heart attack, stroke or even death. Also, injuries could occur to bones, joints or muscles. Slips, falls, and unintended loss of balance could result in muscular, neurological, orthopedic or other bodily injury. I understand that part of the risk involved in undertaking any activity or program is relative to my own state of fitness or health (physical, mental, or emotional) and to the awareness, care and skill which I conduct myself in that activity or program. I understand that proper form of any exercise (as described and/or demonstrated by Trainer) performed by me is a necessary and essential component of an exercise program. Knowing the material risks and knowing and reasonably anticipating that other injuries are a possibility, I hereby expressly assume all of the delineated risks of injury, all other possible risk of injury, and even risk of possible death, which could occur by reason of my participation. I do hereby waive, release and forever discharge Total Strength Fitness and the Back on Track program from any and all responsibilities or liability for any present and future injuries or damages resulting or arising from my participation in any activities including but not limited to exercise, group training, track meets, or use of the equipment used within the Back on Track program.I AGREE AND UNDERSTAND.(Required) Initial Here.Back on Track Policies and Procedures1. The Back on Track Training Program is purchased by an upfront payment of $50 followed by a $100 before the first 4 weeks, the second $100 payment before the second 4 weeks, and a $50 payment for the last 2 weeks of the program. Participant may pay for the program in full up-front if preferred by participant. 2. Total Strength Fitness does not offer refunds for unused sessions by client. 3. PAR-Q and Waiver, and Agreement must be completed, signed, and on file prior to the beginning of the first session. 4. Participant understands that participant is responsible for finding accessible equipment to use for the strength training portion of this program. Modifications can be made due to lack of access to equipment; however, this program will have the best impact when the recommended exercises are completed. Signature(Required)Please provide signature via touchscreen, touchpad or mouse.PaymentOnce you click submit, you will be directed to PayPal for payment. Payment will be accepted via PayPal funds, eCheck or Credit Card. You do not need to have a PayPal account to make payment. If you choose to pay by check, instructions will be provided on where to send your payment.Total 12 Week Program Fee Quantity(Required) Price: $300.00 Quantity Payment MethodPayPalCashNameThis field is for validation purposes and should be left unchanged. Δ
