Your Name (required)
 

Your Email (required)
 

Date 

Address 

City 

State 

Zip 

Date of Birth 

Primary Phone 

Secondary Phone 

Gender Male Female

Occupation 

How did you find out about Beach Fit Now?
 Referred by friend Print Ad Flyer Poster Facebook Twitter Google A Blog Our Website Other

If you were referred by a friend what is their name? 

By entering your friends name here, they receive 3 FREE sessions when you sign up for one or more packages

If you were referred by a blog what is the name of the blog? 

If you saw a flyer, poster , or a print ad where did you see it? 

If other please explain

Height 

Weight 

Age 

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No

Do you feel pain in your chest when you perform physical activity? Yes No

In the past month, have you had chest pain when you were not performing any physical activity? Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No

Do you know of any other reason why you should not engage in physical activity? Yes No

If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Please rank the following items on a scale form 1 (very important) to 10 (not important)

I want to learn proper exercise form 

I want to increase my strength 

I want to lose weight 

I want to be more toned up and firm 

I want to improve my cardiovascular health 

I want to learn the proper foods to eat  

I want to have someone help motivate me 

BEACH FIT NOW RELEASE OF LIABILITY AGREEMENT

1. In consideration of being allowed to participate in the fitness training activities and programs of BEACH FIT NOW, LLC and other classes/events offered by Deanna Meilan and/or her assigned instructors, and to make use of its equipment and services, in addition to any donation and/or payment of any fee or charge, I do hereby forever on my own behalf and, if assigned by me as a parent on behalf of my child, myself and my family, waive, release and discharge Deanna Meilan personally, and/or BEACH FIT NOW,LLC, or the use of any equipment at various sites, including residents place of dwelling or outdoors, provided by and/or recommended by Deanna Meilan and/or BEACH FIT NOW,LLC and it’s assigned instructors, employees and representatives.
2. I have been informed, understand, and am aware that strength, flexibility, and aerobic exercise, including the use of equipment, are potentially hazardous activities. I also have been informed, understand, and am aware that fitness activities, including those performed in water or on sand, involve a risk of injury, including a remote risk of death or serious disability, and that I am voluntarily participating in these activities with full knowledge, understanding, and appreciation of the dangers involved.

I additionally acknowledge that I have undertaken the following personal obligations as a participant in BEACH FIT NOW,LLC including:
1. To engage in appropriate pre-exercise warm-up and post-exercise cool-down stretching and flexibility exercises;
2. To carefully inspect all exercise equipment or modalities prior to use to assure it is in proper working order;
3. Use exercise equipment or modalities, perform flexibility exercises, perform muscular strength or muscular endurance exercises, aerobic activities only in the manner directed;
4. Perform activities at the intensity level appropriate for my general health and physical condition;
5. Purchase appropriate personal exercise equipment as required by the activities I am participation in, including, but not limited to, FUNCTIONAL AND APPROPRIATE athletic shoes;
6. To immediately cease the activity if I feel dizzy, nauseous, or faint, or experience rapid heart beat, extreme shortness of breath, headache, or any other physical symptoms which is unusual for me, and advise my instructor of the occurrence of said symptoms;
7. Discuss with my instructor and my physician any changes in my medical condition which might affect my participation;
8. Discuss with my physician in advance any concerns he/she may have about my participation in fitness testing activities such as body fat assessment, sub-maximal Vo2 assessment, trunk flexion test, and the like;
9. I agree not to participate in activity with Deanna Meilan and/or BEACH FIT NOW, LLC during any period that I am under the influence of alcohol or drugs or taking any prescription medication unless specifically approved by my physician.

I hearby agree to expressly assume and accept any and all risks of injury or death.

3. I do hereby further declare myself to be physically sound and suffering form no condition, impairment, disease, infirmity, or other illness that would prevent my participation or use of exercise equipment or physical activity. I do hearby acknowledge that I have been informed of the need for a physician’s approval for my participation in the exercise activities, programs, and use of exercise equipment. I also acknowledge that it has been recommended that I have yearly or more frequent physical examinations and consultations with my physician as to physical activity, exercise, and use of exercise equipment. I acknowledge that I have either had a physical examination and have been given my physician’s permission to participate, or that I have decided to participate in the exercise activities, programs, and use of equipment without the approval of my physician and do hereby assume all responsibility for my participation in said activities, programs, and use of equipment. I further acknowledge that I have been advised that maintaining good medical insurance coverage is important for all individuals involved in exercise programs and have been encouraged to obtain such coverage.
4. I understand that Deanna Meilan, her trainers and/or BEACH FIT NOW, LLC provision and maintenance of an exercise/fitness program for me does not constitute an acknowledgment, representation, or indication of my physiological well-being, or a medical opinion relating thereto and that I have reached my decision about participation in this program in consultation with my doctor, psychologist, and/or other medical professional.
5. Agree that photographs, pictures, slides, or videos of me may be taken in connection with my participation in this activity without compensation from Deanna Meilan and/or BEACH FIT NOW, LLC or any other, and consent to the use of these photographs, slides or videos for any legal purpose, including the www.beachfitnow.com website.

IMPORTANT NOTICE: THIS IS A BINDING LEGAL AGREEMENT AND RELEASE. IF YOU HAVE ANY QUESTIONS REGARDING IT, YOU SHOULD SEEK THE ADVICE OF YOUR ATTORNEY PRIOR TO SIGNING IT.

I agree to the BEACH FIT NOW, LLC AGREEMENT & RELEASE OF LIABILITYCheck this box to agree to terms

Full Name 

Initials 

FOR MINORS:

If the person whose signature appears above is under age 18, I,
Parent/Gaurdians Name , sign the foregoing Agreement and Release on behalf of my child. I hearby represent that I am the custodial parent of
Minors name 
and have full authority to execute this Agreement and Release of Liability as a parent on behalf of my child, my family, and myself.

MEDICAL HISTORY

Please fill out the medical information below.
Even if you have before… sorry.

Are you allergic to any medication Yes No

Do you take any prescribed medication on a permanent or semi-permanent basis? Yes No

Do you have a seizure disorder (epilepsy)? Yes No

Do you have diabetes Adult or Juvenile? Yes No

Have you ever been found to be anemic? Yes No

Do you have or have you ever had the following diseases?

Heart Disease
 Yes No

Lung Disease:
 Yes No

Kidney Disease:
 Yes No

Liver Disease:
 Yes No

Do you have asthma?
 Yes No

Have you ever had a severe neck injury?
 Yes No

Have you had a broken bone or fracture in the past 2 years?
 Yes No

Describe other conditions that cause pain

It is wise to seek your doctors advice before beginning any health/fitness/nutrition program

Please answer to the best of your knowledge (Choose Yes or No)

High Blood Pressure
 Yes No

High Cholesterol
 Yes No

Feeling Faint or Lightheaded
 Yes No

Thyroid Problems
 Yes No

Arthritis
 Yes No

Autoimmune disorder
 Yes No

Chest Pain
 Yes No

Bouts of fatigue
 Yes No

Bouts of depression
 Yes No

Stress for extended period of time
 Yes No

Diabetes (Juvenile or Adult)
 Yes No

Any disease or syndrome requiring a MD’s supervision
 Yes No

List any Medications

Check the following:

I understand that photos or video may be taken during the course of my involvement in Boot Camp, which may be used for promotional purposes. I understand that my “before & after” photos will not be used for any promotional purposes unless I give written authorization.

I understand there is no refund policy for any class at any time and that my classes are not transferable. If inclement weather prevents a class from taking place it will be offered at another time.

Full Name
 

Date