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Name

Email Address

Street Address

City And State

Zip Code

Phone

Age

Please list any pre-existing conditions:

Please list any medications you are currently using:

Past Surgeries or Injuries

Health & Fitness Goals

Allergies or Sensitivities

Emergency Contact Name & Phone

List Any Weight Training Equipment You Currently Have

*Release Disclaimer: Pre-paid programs do not offer refunds or makeup classes. Any technical or other reason for a missed class and any cancellation or postponement of the scheduled sessions will be charged. I understand that fitness activities involve a risk of injury and assume the full risk of and release Marc D. Thompson from any liability. I do hereby further declare myself to be physically sound to participate in exercises or use of equipment or machinery. ½ hour sessions average about 27 minutes; 1-hour sessions average about 55 minutes. Hour sessions and house calls are double the rates listed. Additional $10 fee per session for check/money order/card. *Release Disclaimer: Pre-paid programs do not offer refunds or makeup classes. Any technical or other reason for a missed class and any cancellation or postponement of the scheduled sessions will be charged. I understand that fitness activities involve a risk of injury and assume the full risk of and release Marc D. Thompson from any liability. I do hereby further declare myself to be physically sound to participate in exercises or use of equipment or machinery. ½ hour sessions average about 27 minutes; 1-hour sessions average about 55 minutes. Hour sessions and house calls are double the rates listed. Additional $10 fee per session for check/money order/card. I have read and understood the release disclaimer

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