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Team Energetics 750 Alpha Drive, Suite A Highland Heights, Oh 44143 (216) 378-1981

Personal Information and Health History

 

Personal Information: Name: ________________________________________ Date of Birth: _______________ Address: _________________________________________________________________ City: ___________________________________ State: ______________ Zip: __________ Home Phone: (____) ________-_________ Mobile Phone (____) ________-___________ E-Mail Address: _____________________ Gender: ______ Height: ______ Weight ______ Occupation/Physician Information: Employer: _________________________________ Work Phone: (_____) _______-________ Occupation: _________________________________________________________________ Primary Care Physician: __________________________ Clinic/Hospital: _________________ Primary Phone: (_____) __________-_________ Secondary Phone: (_____) ________-______ Emergency Contact Information: Please Contact Name: __________________________________ Relationship: _________________________ Primary Phone: (_____) _________-_________ Secondary Phone: (____) _______-_________

Please Read and respond to the following questions regarding your health and fitness background, as well as family medical history. 1. Are you currently under the care of a physician, chiropractor or another health care provider for any reason? *YES *NO If yes, please list the reason: _______________________________________________________ 2. Are you currently taking any medications? Please indicate name, dosage and what medication is used for: _____________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 3. Please list any and all allergies: ___________________________________________________ 4. Please list any and ALL surgeries that you have had (include approximate year): __________ _____________________________________________________________________________


5. Has your doctor ever said that have a bone or joint problem that will made worse by exercising? *YES *NO

 

If yes please circle and explain any conditions in the following: Upper Back/Neck: ________________________

Lower Back: ____________________

Shoulders: ______________________________

Elbows/ Wrists: __________________

Hips: ___________________________________

Knees: _________________________

Ankles/ Feet: ____________________________

Other: __________________________

6. Have you been diagnosed with High Blood Pressure (HBP or Hypertension)? A reading of 140/90 mm/hg or higher. * YES *NO 7. Have you ever experienced chest pains while exercising?

*YES

*NO

8. If answer to question 7 is yes please explain: _______________________________________ _____________________________________________________________________________

*YES

9. Do you smoke?

*NO

If yes, approximate number of cigarettes/packs per day: ________________________________ Family History 1. Do you or any member of your immediate family have any of the following conditions? Please specify which family member if applicable. Me

Family

Me

Family

Heart Disease

*

*

Heart attack

*

*

Hypertension

*

*

High Cholesterol

*

*

Gout

*

*

Angina

*

*

Abnormal EKG

*

*

Diabetes

*

*

Asthma

*

*

Seizure Disorder

*

*

Other Heart Problem *

*

Other:___________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________


Team Energetics W aiver of Release and Liability Health Statement: In requesting permission to access and use the equipment of the Team Energetics Conditioning Center (located at 750 Alpha Drive, Suite A, Highland Heights, Ohio 44143) included but not limited to the batting cages, the multi-sport court, the boxing area, the turf area and other related facilities, I affirm I have been cleared for exercise by a licensed physician and that my general health is good and that I am not adversely affected by the exercise that I will undertake. I further affirm that I am not aware of any physical condition that may adversely affect or prevent me from performing exercise of vigorous nature. I am not currently under the care of a physician who has limited my physical activity. If I am under the care of a physician, I affirmatively state that I have received his/her permission to participate in any/all exercise at the Team Energetics Conditioning Center and its facilities. I hereby certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating in any activity or using any equipment at Team Energetics and I agree to bear the cost of such injury or damage myself. I agree to hold Team Energetics, LTD harmless for any and all liabilities for damages or injuries that occur while I am a participant at the Team Energetics Conditioning Center.

Agreement to Follow Rules and Policies: I understand that the Team Energetics Conditioning Center provides both directed and self directed programs and that I may not be provided with any fitness instruction. I agree to use only such equipment which I know how or am permitted to operate. I agree to follow all rules and policies of Team Energetics, LTD and to abide by any reasonable request concerning use of the facility directed to me by the staff of Team Energetics. I agree to operate and use the equipment only in a manner in which it was designed and intended to be used, following all verbal and written instructions, if any, provided by Team Energetics staff. I understand that my failure to abide by and follow instructions or request may result in a termination of my privileges of using the facility. I further understand that Team Energetics had the right to terminate or alter my privileges at the facilities in their complete and unilateral discretion.

Release and W aiver: I acknowledge that the use of the Team Energetics Conditioning Center and the equipment contained therein, included but not limited to, the fitness center, the batting cages, the multi-sport court, the boxing area, the turf area and all other related facilities entail known and unanticipated risks which could result in serious physical and/or emotional injury, illness, disability, paralysis, death, and/or damage to myself, to property, and to third parties. In consideration for allowing me to use the Team Energetics Conditioning Center and all related facilities, I hereby accept any and all risks related to my health and of my injury, illness, disability, paralysis, and/or death that may result from such participation in any and all activities and/or use of any equipment of facilities and I hereby release Team Energetics, LTD and all of its members, affiliates, parents, managers, employees, officers, agents, predecessors, successors, and assigns from any liability to me, my personal representatives, estate, heirs, next of kin and assigns from any and all claims, suits, causes of action and actions for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from, be related, or occur during my use of the Team Energetics Conditioning Center and equipment contained therein, the batting cages, the multi-sport court, the boxing area, and all other related facilities, whether caused by negligence of Team Energetics, LTD and any of its members, affiliates, parents, managers, employees, officers, agents, predecessors, successors and assigns from any and all liability whatsoever which may result from my use of Team Energetics Conditioning Center and the equipment contained therein, including but limited to the batting cages, the multi-sport court, the boxing area, the turf area, and all other related facilities. This statement shall serve as a release and hold harmless of Team Energetics, LTD and each of it members, affiliates, parents, managers, employees, officers, agents, predecessors, successors and assigns by my heirs, executors, administrators, if any and me. I have had sufficient opportunity to read the entire document and have carefully read this agreement and understand it to be a release and waiver of all claims and causes of action for my injury, illness, disability, paralysis, death or damage to my property that occurs while using the Team Energetics Conditioning Center and the equipment contained therein, including but not limited to the batting cages, the multi-sport court, the boxing area, the turf area, the athletes area, the group fitness room, the golf fitness center, and all other related facilities and it obliges me to indemnify and hold harmless the parties named for any liability for injury, illness, disability, paralysis, death or damage to my property caused by my negligent or intentional act or omission. I acknowledge my right to have this document reviewed by an attorney of my choice prior to signing this. It is my specific intention by signing this document to exempt and relieve Team Energetics, LTD and all of its members, affiliates, parents, managers, employees, officers, agents, predecessors, successors and assigns from liability for personal injury, property damage and/or wrongful death caused by negligence or any other cause.

Signature: ___________________________________________ Date: ____________________ Name (please print): ____________________________________________________________ Witness signature: ____________________________________ Date: ____________________ Name (please print): ____________________________________________________________


Membership Agreement Agreement for Easy Pay Monthly Debt System Electronic Fund Transfer (EFT) By signing this Membership Agreement (“Agreement”) you have authorized Team Energetics, LTD. (“Team Energetics”) to bill your account or credit card for your monthly dues by electronic fund transfer (EFT), pre-authorized check, savings or credit card charge on a monthly basis. Your membership with Team Energetics will continue on a month-to-month basis. You may cancel your membership by giving thirty (30) day written notice to Team Energetics. If Team Energetics is unable to collect your monthly dues for any reason, Team Energetics may impose a Service charge of $20 without notice. Your account will be billed on the third day of every month beginning ______________, 20_____ for the amount of $________. Our dues are processed by Twin Oaks Software development Inc. Member’s Right to cancel this Agreement If you wish to cancel this Agreement, you may do so by giving written notification to Team Energetics at 750 Alpha Drive, Suite A, Highland Heights, Ohio 44143. This notice must be given within seventy-two (72) hours following the execution of this Agreement. You may also cancel this Agreement if you move your residence more than twenty-five miles from Team Energetics. Personal Training Cancellation Policy All personal training clients shall give a minimum of twenty-four (24) hours notice of a cancellation prior to the appointment time. Team Energetics, LTD (“Team Energetics”) reserves the right to determine whether or not to charge for the cancelled session. Team Energetics shall have the right to charge the client the full session price for a missed appointment or if the client fails to give twenty-four (24) hour notice. Each client is allowed 3 emergency cancellations per year without charge. Such cancellations are for unforeseen circumstances that prevent the client from attending the scheduled appointment. Should a client cancel its appointment due to inclement weather, Team Energetics reserves the right to apply the cancellation toward the three (3) emergency cancellations per year, if Team Energetics’ facility is open at the time of the cancellation. If Team Energetics is closed due to inclement weather, the cancellation will not apply toward the three (3) emergency cancellations per year. Client Personal Training Contract Default Penalties A service charge of $60.00 may be assessed upon any client that breaches their Personal Training Contract. In addition to the service charge, the client will be assessed the difference between the cost of the hour in the package purchased and the maximum rate charged by Team Energetics for one (1) hour or one (1) half hour sessions. Account Suspension In the event that a client will not be utilizing personal training services of Team Energetics facilities for a specified period of time, a client must provide not less than thirty (30) days written notice. Following receipt of said notice, Team Energetics will suspend any charges for services until such time as the client is ready to return to Team Energetics to complete their contractual obligations. Acknowledgment ______________ I hereby acknowledge that I have read and understand the foregoing and that I have been provided a copy of same. By: Team Energetics, LTD 750 Alpha Drive, Suite A, Highland Heights, Ohio 44143 ________________________Name (please print) _______Date _____________________Member’s Signature _______Date _______________________Witness Name ________Date _______________________Witness Signature ________Date


Printable Team Energetics Waiver Fourm