Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

*

By checking the box you and typing your name below you are agreeing to allow it to serve as your electronic signature. You (Participant) are also acknowledging to Lauren Stogner Fitness (LSF) to allow the Participant to engage in various physical activities. However, the Participant also hereby acknowledges to LSF that there are inherent risks of various physical and mental conditions, illnesses, and injuries associated with engaging in any physical activity, and that such risks may be compounded by the fact that many of the activities are unsupervised, including without limitation. According, the Participant hereby (a) consents to voluntarily engage in much of the Activities as the Participant may elect to engage in, from time to time, whether supervised or unsupervised, (b) consents to use the Facilities at the sole risk of the Participant and with full knowledge of any and all risks associated with access to or the use of the Facilities or a participation in any of the Activities, and (c) assumes the full responsibility for any and all risks of bodily injury, illness, property damage, or other damage suffered by the Participant resulting from access to or the use of the Facilities or a participation in any of the Activities. Further, the Participant hereby (a) releases, waives, forever discharges, and covenants not to sue LSF for any and all loss, cost, expense, damage, or claims, of whatever kind, character, or description, whether known or unknown, on account of, arising from, or relating in any way to any bodily injury, illness, conditions, property damage, or other damage resulting, in whole or in part, from access to or the use of the Facilities or a participation in any in any of the Activities, and (b) hereby agrees to indemnify and hold LSF harmless from and against any and all loss, cost, expense, damage, or claims, of whatever kind, character, or description, resulting, in whole or in part, from access to or the use of the Facilities or a participation in any of the Activities.

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Please check if you suffer or have suffered from the following: *

Heart Condition

Chronic Fatigue

Epilepsy or Seizures

Neuromuscular Disorders

Pregnant

Type I Diabetes

Type II Diabetes

Emphysema

Gallbladder Disease

Cancer

Remission of Cancer

Chest Pain

Kidney Disease

Blood Disorder

Chronic Bronchitis

Gastrointestinal Issues

Anorexia

Bulimia

Depression

Dizzy Spells

Bone or Joint Disorder

High Blood Pressure

High Cholesterol

Arterio or Athero Scleroisis

Smoke

Lung or Pulmonary Disease

Family History of Heart Disease

Family History of Diabetes

Family History of High Cholesterol

Food Allergies

Special Dietary Needs or Care

Alcohol Dependency

Attention Deficit Disorder

Panic Attacks or Paranoia

Currently Taking Prescription Medication

Other

Have you suffered or do you suffer from orthopedic issues? *

Yes

No

Have you suffered or do you suffer from muscular issues? *

Yes

No

*

By checking the box you and typing your name below you are agreeing to allow it to serve as your electronic signature. It is Lauren Stogner Fitness’ (LSF) policy that all participants be cleared by a medical doctor prior to utilizing this facility and/or participating in any exercise program. This screening tool is NOT designed or intended to diagnose any medical condition(s) nor is it a substitute for a full medical exam that must be performed by a qualified medical doctor prior to your voluntary participation in an exercise program. By signing this document you are indicating that you understand this form and that you have consulted – or WILL – consult a medical doctor prior to engaging in an exercise program. Furthermore, you agree not to hold this company or any of its agents, officers, or employees – past or present – liable for any issues, injuries, or complications that may arise from your voluntary decision to utilize facilities, equipment, and/or professional services.

Name *

First Name

Last Name

Are you looking to compete? *

Yes

No

Maybe

How many days per week do you do resistance training? *

1-2 Days/Week

2-3 Days/Week

3-4 Days/Week

4-5 Days/Week

5-6 Days/Week

7 Days/Week

I don't workout

How many days per week do you do cardio? *

1-2 Days/Week

2-3 Days/Week

3-4 Days/Week

4-5 Days/Week

5-6 Days/Week

7 Days/Week

I don't do cardio

How many minutes of cardio do you perform at each session? *

0-15 min

15-20 min

20-30 min

30-45 min

45-60 min

over 60 min

*

By checking the box and typing your name below you are agreeing to allow it to serve as your electronic signature. It is Lauren Stogner Fitness' (LSF) policy that all participants be cleared by a medical doctor prior to utilizing this facility and/or participating in any exercise program. This screening tool is NOT designed or intended to diagnose any medical condition(s) nor is it a substitute for a full medical exam that must be performed by a qualified medical doctor prior to your voluntary participation in an exercise program. By signing this document you are indicating that you understand this form and that you have consulted – or WILL – consult a medical doctor prior to engaging in an exercise program. Furthermore, you agree not to hold this company or any of its agents, officers, or employees – past or present – liable for any issues, injuries, or complications that may arise from your voluntary decision to utilize facilities, equipment, and/or professional services.

Date

MM

DD

YYYY

Name *

First Name

Last Name

How many (oz) of water do you drink per day? *

0-16 oz

16-32 oz

32-48 oz

48-64 oz

64-96 oz

96-128 oz

128 oz or more

How many times per week do you eat out *

None

1-2 times per week

2-3 times per week

3-4 times per week

4-5 times per week

5-6 times per week

7 or more times per week

How often do you have a "cheat meal"? *

Never

1 time per month or less

1-2 times per week

2-3 times per week

3-4 times per week

4-5 times per week

5-6 times per week

7 or more times per week

Do you have any food allergies? *

Yes

No

Do you have any food intolerances? *

Yes

No

Do you take supplements? *

Yes

No

Would you be interested in taking supplements? *

Yes

No

Which type of supplements would interest you most *

None

Overall Wellness

Digestion

Meal Replacements

Muscular Increase

Fat Loss

Performance

Recovery

Sleep

Heart Health

Energy

Other

*

By checking the box you and typing your name below you are agreeing to allow it to serve as your electronic signature. It is Lauren Stogner Fitness' (LSF) policy that all participants be cleared by a medical doctor prior to utilizing this facility and/or participating in any exercise program. This screening tool is NOT designed or intended to diagnose any medical condition(s) nor is it a substitute for a full medical exam that must be performed by a qualified medical doctor prior to your voluntary participation in an exercise program. By signing this document you are indicating that you understand this form and that you have consulted – or WILL – consult a medical doctor prior to engaging in an exercise program. Furthermore, you agree not to hold this company or any of its agents, officers, or employees – past or present – liable for any issues, injuries, or complications that may arise from your voluntary decision to utilize facilities,*