Training Intake Form

Phone (optional)

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Are you working with any of the following? *

heart disease

diabetes

blood pressure (high or low)

stroke

cancer

bone/joint issues

asthma

neurological condition

other

none of the above

How much water do you drink on a typical day?

little to none: I'm a camel

I stay hydrated, 8-10 glasses a day

I honestly don't know, it's not a priority of mine

Do you agree that if you engage in any physical exercise or activity, including personal training, at your home, online or in-person at an agreed upon location or use any facility or equipment for any purpose, you do so at your own risk and assume the risk of any and all injury, illness and/or damage you may sustain. *

Yes I agree, & I will get cleared with my doctor before training!

No, I don't agree.

RELEASE: You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Trainer Ann Bruck (and Trainer’s affiliates, related entities, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Trainer whether active or passive, or any of Trainer’s affiliates, 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) exercise equipment (c) or at home workouts performed without the trainer present *

Yes! I am an adult and will respect my own body!

I wish to sue your pants off for no reason.