If you answered yes to any questions above, please explain:

Have you ever had any major illnesses and/or injuries?                                          YES     NO

            If yes, please explain

Are you presently receiving physical therapy?                                                       YES     NO

            If yes, please explain

Are you presently taking any medications?                                                          YES     NO

            If yes, please explain

Do you have a family history of heart disease (heart attack, stroke, etc.)?                YES     NO

Do you have a family history of high blood pressure?                                            YES     NO

Do you have a family history of diabetes?                                                           YES    NO

Do you know of any reason that you should NOT engage in this program?                YES     NO
 

 EXERCISE HISTORY:

Are you presently involved in a regular exercise program?                                      YES     NO

If yes, please list activities/duration/frequency/intensity

Have you ever been involved in a “Sports Specific” Strength Regimen?                     YES    NO

If yes, please list activities/duration/frequency/intensity

Are you now or have you ever been on a diet?                                                    YES     NO

            If yes, please explain

Are you currently taking any dietary or “sports performance” supplements?               YES     NO

            If yes, please describe

Do you consider yourself overweight?                                                                YES    NO
Do you consider yourself underweight?                                                               YES    NO

How many meals do you usually eat per day?

How would you describe your nutrition habits? (check)          Poor                 Fair                  Good

How would you characterize your life? (check)          Low Stress     Moderate Stress                       High Stress

Are there any other comments you would like to give concerning your health?

FITNESS/ATHLETIC GOALS:

Please check 3 – 5 of your top goals:

   Improve Strength                                      Decrease Injury

  Improve Conditioning                                  Rehabilitate Injury

   Improve Agility/Coordination                         Decrease Body Fat%/Weight

   Gain Muscle/Weight                                    Improve Nutrition

Improve Flexibility                                       Other (please specify):

Please expand on goals or comment on time frame (if appropriate)

I do hereby state that I have, to the best of my knowledge and belief, given a correct and accurate medical history report.
(Initials) Date:
 

Waiver and LiabilityThe FIT Potato Personal Fitness Training Services Waiver, Release of Liability, and Assumption of Risk READ CAREFULLY BEFORE SIGNING I have been informed, understand and am aware that activities such as, but not limited to running, jumping, hurdling and other fitness and movement activities, cardiovascular, flexibility and/or strength exercises are potentially hazardous activities. I also have been informed, understand and am aware that fitness and movement activities involve a risk of injury; including the risk of death or serious disability, and that I am voluntarily participating in these activities with full knowledge, understanding and appreciation of the danger involved. I hereby agree to expressly assume and accept any and all risks of injury, illness, death, or related situations. _______ (please initial)   In consideration of being allowed to participate in fitness training and activities with The FIT Potato Personal Training Services, facilities and equipment, the undersigned acknowledges, appreciates, and agrees that:   The risk of serious injury, including but not limited to permanent paralysis, injury and death, is significant and does exist, even though particular rules, equipment and personal discipline may reduce the risk; and    I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, even if arising from the negligence or omission of The FIT Potato Personal Training Services, and their officers, agents, employees, contractors and volunteers or others, and assume full responsibility for my participation; and    I willingly agree to comply with the stated and customary terms and condition of participation. If I observe any unusual significant hazard during my presence or participation, I will remove the hazard, if possible, discontinue my participation, and/or bring such to the attention of the nearest employee of The FIT Potato Training Services immediately.    I, for myself, my heirs, assigns, personal representatives and next of kin, do herby forever waive, release, discharge, and hold harmless Francisco Gomez and The FIT Potato Training Services and their officers, agents, employees, contractors and volunteers from any and all claims or liabilities for injuries, disability, death, or loss or damage to person or property, whether arising from the negligence or omission of  Francisco Gomez and The FIT Potato Training Services, Dublin Unified School District, Dublin city Parks, Pleasanton Unified School District, Pleasanton city parks, Livermore city park, Livermore Unified School District  and their officers, agents, employees, contractors and volunteers. _______ (please initial)    I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent me from safe participation in health, fitness or movement activities with The FIT Potato Training Services. In entering into this Agreement with The Fit Potato Training Services, the undersigned acknowledges that this affirmative statement is a material consideration of participation in The FIT Potato Training Services programs.   I HAVE READ THIS WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS AND SIGNIFICANCE, UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. I ACKNOWLEDE, BEING AWARE OF MY OWN HEALTH AND PHYSICAL CONDITION, AND HAVING KNOWLEDGE THAT MY PARTICIPATION IN THIS HEALTH AND FITNESS PROGRAM MAY BE INJURIOUS OR HAZARDOUS TO MY HEALTH AND ORWELL BEING, THAT MY PARTICIPATION IN THIS FITNESS PROGRAM IS VOLUNTARY AND WITH FULL UNDERSTANDING, ACCEPTANCE, AND ASSUMPTION OF ALL RISKS INVOLVED.

This form is an important legal document that explains the risks you are assuming by taking place in exercise and movement activities. It is critical that you have read and understand this document completely.

(Initials) Date:

FOR MINORS (UNDER 18)

This is to certify that I, as parent or legal guardian, have legal responsibility for this participant. I have read and understand the significance of this Waiver and Release and do consent and agree to his/her waiver, release, and assumption of the risk as provided above. I release and agree to indemnify and hold harmless The FIT Potato Training Services, and their officers, agents, employees, and volunteers from any and all liabilities for injury to the above minor while participating in the program, EVEN IF ARISING FROM THE NEGLIGENCE OR OMISSION of The FIT Potato Training Services, or their officers, agents, employees, and volunteers.

(Initials) Date:

(Parent/Legal Guardian Signature)