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Please fill out the following multi-step form. Required fields have an asterisk (*).

Class Session*:
First Name*:
Last Name*:
T-Shirt Size:
E-mail Address*:
Address*:
 
City*:
State*:
Zip*:
Phone*: 
Emergency Contact Name*:
Emergency Contact Relationship:
Emergency Contact Phone*:
Fitness Level:
Please rate your current fitness level with 10 being highest
Describe your current exercise routine:
What are your fitness goals:
YesNoPhysical Activity Readiness*:
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do a physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Please indicate any additional medical information that you think is important for us to know prior to fitness testing and exercise. Example: knee or back problems:
How did you hear about LiveWire Fitness?:
Questions/Comments:
Waiver of Liability and Informed Consent:

I agree to the following:

  1. I am participating in the fitness programs offered by LiveWire Fitness and recognize this requires physical exertion, which may be strenuous and may cause physical injury. I am fully aware of the risks involved.
  2. I represent and warrant that I am physically fit and have no medical condition which would prevent my full participation in the fitness programs. I understand it is my responsibility to consult with a physician prior to and regarding my participation in fitness programs.
  3. I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which might occur as a result of participating in the fitness program.
  4. I hereby execute and deliver this waiver releasing LiveWire Fitness from and against all claims, costs, liabilities, expenses, and judgment, including attorney's fees and court costs arising of my participation in the program, or any illness or injury while participating in the program. I hereby release any claim I may have against LiveWire Fitness for any injury or death caused by their negligence or other acts.
  5. I, my heirs or legal representatives forever release, waive, discharge, and covenant not to sue LiveWire Fitness for any injury or death caused by their negligence or other acts.
  6. I give LiveWire Fitness full consent to capture pictures/images of my likeness during my participation in LiveWire Fitness classes without requiring remuneration for the same. I agree to release any and all images of this nature to LiveWire Fitness and agree to their usage by LiveWire Fitness in their promotions and on the LiveWire Fitness website.