BootCamp Program Health History Form and Waiver of Liability


Tel. No(s):



Health History:
1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

2. Do you feel pain in your chest when you perform physical activity?

3.  In the past month, have you had any chest pain
when you were not performing any physical activity?

4.  Do you lose your balance because of dizziness
or do you ever lose consciousness?

5.  Do you have a bone or joint problem that could
be made worse by a change in your physical activity?

6.  Is you doctor currently prescribing any medication for your blood pressure or for a heart condition?

7.  Do you know of any other reason why you should not engage in any physical activity?

8.  Have you ever had any pain or injuries?
(ankle, hip, knee, neck, back, shoulder, etc.)

9.  Have you ever had any surgeries?

10. Has a doctor ever diagnosed you with a chronic disease such as coronary heart disease, coronary artery disease, hypertension, high cholesterol,
diabetes or asthma?

11. Is there any other information about your health and/or physical condition that should be known?

Please use the space below to comment on or clarify any of your "Yes" answers:
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tel:  917.289.0924 for more info
Personal Information:
I, the undersigned participant ("CLIENT"), am hereby enrolling in a fitness program of strenuous physical activity including, but not limited to, speed training, weight lifting, plyometrics, and the use of various aerobic conditioning and strength training machinery and equipment conducted by Juliette Soucie and/or Move-By-Design ("COMPANY"), and agree as follows:

I have been strongly encouraged to consult with my physician prior to starting an exercise program or increasing the intensity of an existing program, indicated both in this document and by COMPANY. I assume this responsibility as indicated by my signature and if I choose to, will act on this advice prior to the implementation of any recommendations made by COMPANY.

I hereby affirm that, to the best of my knowledge, I do not suffer from any condition that would prevent or limit my participation in this fitness program and have not withheld any related information from COMPANY.

I understand that since the effects of the program depend, in part, upon the efforts of the CLIENT, results may vary from individual to individual.  I understand that since that the nature and purpose of the program require me to engage in strenuous physical activity, and I am aware that any strenuous physical activity involves risks, I hereby assume the risk of any and all accidents and injuries of any kind which may be sustained by me because of or in connection with my participation in the program, and hereby release, discharge, and absolve COMPANY from any and all liability or responsibility for any such accident or injury.
If you answered "YES" to any of the above questions,  please consult with your physician before engaging in physical activity.
Emergency Contact Info:

Tel. No:      Relationship:

Before you can participate in your first Build-A-Bootcamp or BootCamp "Try-Outs", you must fill out this Health History Form and indicate that you have read the Waiver of Liability and agree to the Terms and Conditions  (shown below). Once you have pressed "Submit," you are ready to report for your registered BootCamp session.
You will receive an email confirmation of your registration.

You will need to sign a copy of this form and waiver when you report for your first BootCamp session.

Please know that all your information is kept strictly confidential.
Please hit "Submit" to complete your Registration.  You will be asked to sign a hard copy of this form and waiver of liabilitiy on the date of your participation in your first BootCamp session.
Need help or more information?
Please call us at 917-289-0924 or
email me
You will be given a hard copy of this Waiver to sign at your first session.
All your information is kept strictlly confidential.
2010 Move-By-Design Personal Training NYC.  All rights reserved.
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tel: 917-289-0924email:
I have consulted a Medical Professional.
I have read and agree to the Terms of the Waiver Of Liability.