Personal Training Registration

I am a...

Notes: If you are a returning client without changes to your profile, please proceed through checkout, otherwise please fill out the form completely.

Returning Clients, note your profile changes here*

Which Session You Would Like to Join Us?

How Many Sessions?*

Contact Information

First Name*

Last Name*

Email*

Address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Primary Phone Number*

Cell Phone Number

Home Phone Number

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

Do you regularly take any prescription medications?*

Yes
No

Do you have seizures (epilepsy)?*

Yes
No

Do you have diabetes Adult or Juvenile?*

Yes
No

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

Yes
No

Do you have High Blood Pressure (hypertension)?*

Yes
No

Have you ever had the following diseases?

Heart Disease
Lung Disease
Kidney Disease
Liver Disease

Do you have asthma?*

Yes
No

Have you ever had a neck or back injury?*

Yes
No

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

Yes
No

Have you ever been knocked out?*

Yes
No

Do you have chronic back pain?*

Yes
No

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

Yes
No

Do you have other physical conditions, which cause pain?*

Yes
No

Do you wear glasses or contacts?*

Yes
No

If you answered yes to any of the above, please describe:

Fitness Goals

What are your goals for the next three months?*

Are you training for a specific event?*

Yes
No

Have you had your body fat tested?*

Yes
No

If yes, what percentage?*

Other Information

How did you hear about us?*

Please tell us where?*

Describe your current training routine*

I am very consistent with my training routine
I work out, but I am inconsistent
I have not worked out in weeks
I have not worked out in months
I have not worked out in years
I have never worked out

Payment Information

Your credit card information will be sent through our secure online shopping cart payment system. To submit payment, you can either:

Submit your credit card information through our secure shopping cart
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

I will be paying by:*

Cash
Check
Credit Card

Are you entitled to a discount?*

Yes
No

If yes to discount, please explain*

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 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.

I understand that all pictures taken by VyAyr Fitness are owned by VyAyr and may be used in marketing materials for VyAyr Fitness.

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

Email

This field is for validation purposes and should be left unchanged.

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