Demographic & Payment Information

Christine L. Flora ~ Tuffgirls Boot Camp

Demographic Information: Name (Last): ______________________________ (First): ______________________________ (MI): _____ DOB: ___________ Age: _______ Gender: _______ Phone: ________________________

E-Mail: ____________________________________________________________________________________ Emergency Contact: ______________________ Phone #: ________________Relation: _____________ Payment Information: FEES are as follows:

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$100 for 6 sessions Punch Card (Expires in 60 days) $150 for 12 sessions Punch Card (Expires in 90 days)

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$20/session DROP-IN $15 discount BFF deal (you and a friend sign-up together, same day group of 2)

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Cash: $____________ Date: ____________ Check: $_____________#________________ Credit Card: $___________ Last 4________

Int: _________ __ Int: _________ __ Int: _________ __

Int: _________ Int: _________ Int: _________

*there is a 2.75% fee per swipe for all credit card transactions

Informed Consent & Release of Liability I Christine L. Flora ~ Tuffgirls Boot Camp PAR-Q
Regular physical activity is associated with many health benefits, but a sudden change in activity level may increase the risk of injury.

Please read each of the following questions carefully and answer them honestly.

Has a physician ever said that you have a heart condition and recommended only medically supervised activity? Yes No Do you have chest pain brought on by physical activity? Yes No In the past 6 weeks have you experienced pain in your chest while NOT being physically active? Yes No Have you on one or more occasions lost consciousness or fallen over as a result of dizziness? Yes No Do you have a bone or joint problem that could be aggravated by physical activity? Yes No Are you currently taking prescription heart or blood pressure medication? Yes No Are you pregnant? Yes No Do you have insulin-dependent diabetes? Yes No Would you describe your lifestyle (up until now) sedentary? Yes No Are you aware of any other reason that would prohibit you from exercising without medical supervision? Yes No If Yes, please explain: ____________________________________________________________________________________________________ I, the undersigned participant, recognize that exercise involves some risk to the musculoskeletal system (e.g. sprain, strain) and cardio respiratory system (e.g. dizziness, fainting, abnormal heartbeat, discomfort in breathing, abnormal blood pressure response, and in rare instances, heart attack and stroke). I hereby certify that I have no medical problems, and I hereby agree that all exercise, participation in programs, and use of equipment shall be undertaken by me at my sole risk, and accept risk of illness or injury as a result of my participation in any activities or my use of the equipment. I also understand that I assume this risk at all times. I further understand that it is my responsibility to report immediately to Christine L. Flora any signs or symptoms of discomfort and/or distress during or following exercise. Additionally, I hereby consent to the administration of first aid and resuscitative measures by Christine L. Flora. I do expressly hereby forever waive, release and discharge Christine L. Flora ~ Tuffgirls Boot Camp and, her respective servants, agents, and independent contractors from any and all claims, demands, injuries, actions, causes or courses of action, judgments, expenses, liability, or other damage or loss to me or my personal property which may arise out of my participation in Christine L. Floras ~ Tuffgirls Boot Camp and/or participation in any exercise programs, and from all acts of active or passive negligence on the part of Christine L. Flora, or her servants, agents, or contractors. By signing below, I acknowledge that I have read and understand this Consent and Release in its entirety and voluntarily agree to all of the provisions contained herein. __________________________________________ Applicant Signature __________________________________________ Witness Signature _______________ Date _______________ Date ______________________________________ Printed Name ______________________________________ Printed Name