VYBES FITNESS

PRE-EXERCISE SCREENING FORM AND AGREEMENT

Name: ________________________________________ Age: __________ Sex: M / F (Please tick/circle)
D.O.B: _______________________________ Height:____________________________
Address:________________________________________________________________________________________
Tel. (H): _____________________________ Mobile:_________________________
Email: __________________________________________________________________
Have you ever suffered from any of the following medical conditions?
MEDICAL CONDITION
YES
NO
Diabetes
Stress or High Blood Pressure
Asthma or Respiratory illness
Heart or Chest Pains
Epilepsy, Fainting or Dizziness
Arthritis
Neck or Back Pain
Any other Muscle or Joint Pain? _____________________
Please Specify: _______________________________________________________________________________________
Are you being treated for any other Medical Condition? __________________________
Please Specify: _______________________________________________________________________________________
Are you pregnant? YES NO (Please tick/circle)
Have you had a baby in the last six months? YES NO (Please tick/circle)
Do you smoke? YES NO (Please tick/circle)
If YES, how many per day? _____________
Has your Doctor, or any health care professional ever advised you against any form of exercise?
YES NO (Please tick/circle).
If YES, please explain:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Are you presently taking any medication that may prevent or put you at risk of undertaking any form of high
intensity exercise? YES NO (Please tick/circle)
If YES, please provide details:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Are you currently on a specific diet? YES NO (Please tick/circle)
If YES, please give details:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

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VYBES FITNESS
Are you aware of any injury, past or present, which may be aggravated by any form of exercise?
YES NO (Please tick/circle)
If YES, please explain:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please tick one of the following boxes to indicate the amount of physical activity you perform on a daily basis:
Very Low Low Moderate Active Very Active

Which types of training have you had previous experience with?

TYPE
EXAMPLES
YES NO (please write Y or N)
Cardiovascular training
Walking, Jogging, Running
Endurance training
Long distance running
Strength training
Free weights, resistance machines
Flexibility training
Yoga, Pilates
Hypertrophy training
Bodybuilding
Regular gym sessions
Other (Please specify)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please specify any current or past sport/s you have played:
Current: ___________________________________________________________________
Past: ___________________________________________________________________
How do you perceive your current level of fitness?
Low Average Good High

What are your health and fitness goals?

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
How many times per week are you looking to train? ___________________________________________________
Which days and times would you prefer to train?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
USE OF PICTURES, FILM OR LIKENESS
I agree to allow Vybes Fitness, its directors, instructors and employees to use pictures, film or etc of me for marketing, advertising
or promotional purposes.
Signature of Participant: ________________________________
Date: ________________
Signature of Parent or Guardian: _________________________

Date: ________________

Parent or Guardian Print Name: _______________________________________________

*If the participant is under the age of 18 a parent or guardian must sign.

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VYBES FITNESS
WARNING
Programs and training offered by Vybes Fitness have components of HIGH INTENSITY ACTIVITY and it is your responsibility to
inform your trainer/fitness instructor of any medical condition which may put your health or wellbeing at risk before beginning any
Vybes Fitness exercise program. It is important that you are well hydrated and medically fit before participating in any Vybes
Fitnesstraining session or program. Failure to do so can put your health at serious risk.
DISCLAIMER
I understand that my participation in the activities, programs or services offered by Vybes Fitness and the use of any exercise equipment are
potentially hazardous activities and may involve a risk of injury, and I hereby agree to assume all the risks associated with my participation,
including any risks arising from any medical or physical condition/s I may have or develop. I also indemnify and agree to hold harmless Vybes
Fitness and its directors, instructors, employees, agents, volunteers and independent contractors in respect of any event that may arise from any
cause whatsoever including, but not limited to, the negligence of Vybes Fitnessand its directors, instructors, employees, agents, volunteers and
independent contractors which results in any damage to property, loss or theft of property, or any accident, injury, loss suffered by or occasioned
to me or any person in my care and control.

I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS FORM I AM
WAIVING CERTAIN LEGAL RIGHTS (INCLUDING THE RIGHT TO SUE) WHICH I OR MY HEIRS, NEXT OF KIN,
EXECUTOR, ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST VYBES FITNESSAND ITS DIRECTORS,
INSTRUCTORS, EMPLOYEES, AGENTS, VOLUNTEERS AND INDEPENDENT CONTRACTORS. ANY QUESTIONS I
HAD WERE ANSWERED TO MY FULL SATISFACTION.
If the participant is under the age of 18 a parent or guardian must sign.
Signature of Participant: ________________________________ Date: ________________
Signature of Parent or Guardian: _________________________ Date: ________________
Parent or Guardian Print Name: _______________________________________________

PRE-EXERCISE SCREENING FORM AND AGREEMENT

Costs of Services
*Individual weekly rate $3,000
*Group weekly rate:
2 persons- $2,500 each
3 persons -$2,000 each
*please note that you are responsible to find your own group unless otherwise informed

Schedule
Monday- Saturday (4 days a week for 2hrs a day)
Personal Training
Your personal trainer will take care of everything from nutrition/diet advice, strength & fitness programming and regular
assessment to the motivation needed to keep you on track to quickly achieve your weight management, strength or
fitness goals. Our work out includes but is not limited to:
* Weights
* Strength training
* Weight loss and body sculpting & toning
* Aerobics
* Resistance training
* Meal plans

Boot Camp Special events coming up for Carnival!

Struggling to lose those last few kilos? Want to get fit, torch some body fat and improve your strength and body
composition? Boot Camp runs all year round with 4 sessions each week designed to maximise weight/fat loss while
significantly improving your strength & fitness levels in a positive and supportive environment. Sign up today!

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tel: 508- 28 54 email: livingproofsm@gmail.com