BASIC INFORMATION Name * First Middle Last Address * Address Line 1 Address Line 2 City — Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState Zip Code Phone (Personal) * Phone (Work) Email * Date of Birth * Weight (lbs) * Height (Feet & Inches) * Gender *MaleFemaleNon-BinaryTrans-MaleTrans-Female Physician Name Physician Number Insurance Carrier Emergency Contact Name * Emergency Contact Number * I am enrolling in: *Personal Training One-to-one (online)Personal Training One-to-one (studio)Personal Training One-to-one (mobile gym)Personal Small Group Training (The Squad)Boot Camp ClassCorporate Booking Boot Camp Class I was referred by:Friend/FamilyCo-workerAdvertisementSocial MediaOther RISK ASSESSMENT Have you ever had any form of heart disease? * Yes No Have you ever experienced shortness of breath or chest pain? * Yes No Date of last full physical: Do you have any or do any of the following pertain? Please explain to the the best of your abilities. High Blood Pressure: * Yes No Levels: * High Cholesterol Level: * Yes No Levels: * Cigarette Smoking: * Yes No How many per day? * Smoked in past: * Yes No How long? * Diabetes: * Yes No Insulin Dependent? * Family history of heart disease: * Yes No Please Explain: (Who/Age) * Abnormal resting EKG: * Yes No Please Explain: * Are you active: * Yes No Please describe your level of activity: (Activity of Exercise) (Times per week) (Minutes per session) * Are you currently taking any medication? * Yes No Please Explain: * Do you have any problem areas? * Yes No Knees * Yes No Please Explain: * Lower Back * Yes No Please Explain: * Neck/Shoulders * Yes No Please Explain: * Hips/Pelvis * Yes No Please Explain: * Flexibility * Yes No Please Explain: * Any other * Yes No Please Explain: * AGREEMENT Agreement Checkbox * I Agree to participate in SF Squared, Inc. (“SF SQUARED”) fitness exercises/classes/programs/training sessions with a certified SF SQUARED instructor. I recognize that exercise is not without varying degrees of risk of illness and/or injury. I hereby certify that I know of no medical problems that would increase my risk of illness and/or injury as a result of participation in fitness exercises/classes/programs/training sessions offered by my instructor and/or by SF SQUARED. I understand and have been informed that there exists the possibility of adverse changes and/or injuries during the fitness exercise/class/program. I have been informed that these changes and/or injuries could include, but in no way are limited to, abnormal blood pressure, fainting, abnormal heart rhythm, stroke, heart attack, orthopedic injury, muscle cramps, and/or pinched nerve. I hereby agreed to waive, release, remise and discharge SF SQUARED and its agents , officers, directors, shareholders, principles, contractors, employees, executors, heirs and assignees of any and all claims, demands, actions, costs, liabilities, debts, or damages of any kind resulting from participation in SF SQUARED fitness exercises/classes/programs/training sessions. The undersigned hereby releases SF SQUARED, waives any and all claims and represents and warrants that they understand and assume any and all risk of illness or injury associated with participation in SF SQUARED fitness exercises/programs/training sessions. Signature * Clear Signature Dated: Submit