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Program Information

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Note: If you are a returning client without changes to your profile, you may skip the Medical History section below and proceed through checkout, otherwise please fill out the form completely.

Which Session You Would Like to Attend?
Time of Day that Works for You
How Many Days You Would Like to Join Us?
Notes:

Contact Information

First Name

Last Name

Email Address

Address

City

State

Zip

Primary Phone Number

(required)

Cell Phone Number

(optional)

Home Phone Number

(optional)

Birthdate

Emergency Contact Information

Contact Name

Contact Phone Number

Contact Relationship

Medical History

Note: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program!

Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?

Yes No

If yes, please describe:

Do you regularly take any prescription medications?

Yes No

If yes, please describe:

Do you have seizures (epilepsy)?

Yes No

Do you have diabetes Adult or Juvenile?

Yes No

If yes, please describe medication:

Have you ever been found to be anemic (low blood count)?

Yes No

Do you have High Blood Pressure (hypertension)?

Yes No

If yes, please describe medication:

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

If yes, please describe medication:

Have you ever had a neck or back injury?

Yes No

If yes, please describe:

Have you had a broken bone or fracture in the past 2 years?

Yes No

If yes, please describe:

Have you ever been knocked out?

Yes No

If yes, please describe:

Do you have chronic back pain?

Yes No

If yes, please describe:

Have you had knee pain in the past 2 yrs that has disabled you longer than a week?

Yes No

If yes, please describe:

Do you have other physical conditions, which cause pain?

Yes No

If yes, please describe:

Do you wear glasses or contacts?

Yes No

Detail any surgical procedures:

Fitness Goals

What are your goals for the next three months?

Have you had your body fat tested?

Yes No

If yes, what percentage:

Other Information

How did you hear about us?

Please specify

Describe your current training routine

Do you have specific fitness goals?

Yes No

If yes, please describe:

Are you training for a specific event?

Yes No

Please specify which one

Payment Information

Your credit card information will be sent through our secured online payment system.

To submit payment, you can either:

Submit your credit card information online
Call your credit card information in to (415) 412-1558
Mail a check to the following address:

VyAyr Fitness for Women
3320 Octavia #8
San Francisco, CA 94123
Walk in with cash

I will be paying by:

Cash Check Credit

Credit Card Holder's Name

Credit Card Number

Type of Card

Credit Card Expiration Date

(mm/yy)

Are You Entitled to a Discount

Yes No

Refund Policy

Thank you for choosing VyAyr Fitness. We understand that life happens and your plans may need to change. In order to receive a refund, you must notify the VyAyr office of your cancellation 3 days prior to the start of your session. (That would be by the end of day Thursday prior to your session). Any changes made after the cut-off deadline will be charged a $25 processing fee. Cancellations made after the session starts will be issued a credit towards a future VyAyr Fitness Boot Camp to be used within one year.

Waiver and Liability Release

WAIVER AND ASSUMPTION OF RISK

I voluntarily agree to this Waiver and Assumption of Risk in favor of the Owner, VyAyr Fitness, in consideration for the opportunity to receive instruction from the Owner or the Owner's employees, and/or to engage in the activities sponsored by the Owner, as follows:

I understand that there are certain risks and dangers associated with the activity and being outdoors and that these risks have been fully explained to me.

I fully understand the danger involved.

I fully assume the risks involved as acceptable to me and I agree to use my best judgment in undertaking these activities and follow all safety instructions.

I waive and release the Owner from any claim for personal injury, property damage, or death that may arise from my participation in the activities or instruction.

I am a competent adult and I assume these risks of my own free will.

Please type agree in this box below stating that you agree to and have read the Waiver and Liability Release above.