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Personal Training/ Evaluation Liability Waiver & Relaease

Please fill out this form to the best of your ability

Personal Information

First name*

Last name*

Email*

Phone

Gender*

Male

Female

Birthday*

Month

Day

Year

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone Number*

Emergency Contact Relationship

Please select your age group for exercise class selection:*

>55 years old

55-60 years old

60-65 years old

65-70 years old

70-75 years old

75-80 years old

80+ years old

Resistance Training History

Choose the option that best suits you:*

No prior experience

Aerobic (Yoga/ Tai Chi/ etc)

Prior experience (no training in last 6 or more months)

1-2 days per week light training for under 6 months

2-3 days per week for over 6 months

Regular resistance training for over 1 year

Vigorous resistance training for over 1 year

Orthopedic History

Neck Pain?*

Yes

Shoulder Pain?*

Yes

Thoracic Spine Pain? (Between Shoulder Blades)

Yes

Lumber Spine Pain? (Lower Back)*

Yes

Hip Pain?*

Yes

Knee Pain?*

Yes

Do you have any other orthopedic concerns? (optional)

Health History

Heart Conditions? (select all that apply)*

None of the below

Chronic Heart Failure

Stroke

Prior Heart Attack

Heart Rhythm Disorder

Angina

Pacemaker/ Fibrillator

High Blood Pressure

Peripheral Artery Disease

Other

Have you ever experienced any of the following during physical activity? (select all that apply)*

None of the below

Chest pain or discomfort

Shortness of breath beyond normal exertion

Dizziness or fainting

Heart palpitations

Lung Conditions*

Yes

Liver Conditions?*

Yes

Kidney Conditions?*

Yes

Neurological Conditions?*

Yes

Metabolic Conditions*

Yes

Do you currently have cancer cancer?*

Yes

have you previously had cancer?*

Yes

Do you currently have physician clearance to participate in exercise if required?*

Yes

Has a doctor ever advised you to limit or avoid exercise?*

Yes

Have you had a fall in the last 12 months?*

Yes

Will your ability to balance hinder your ability to perform moderate exercises?*

Yes

Medications

Are you taking any medications?*

Yes

Concerns

Please list concerns below: (optional)

Goals

Select all that apply:*

Longevity

Independence

Increase Muscle Mass

Increase Bone Density

Balance

Weight Loss

Looks

Other

Health Information Confirmation

I affirm that the information provided in this health questionnaire is accurate and complete to the best of my knowledge.

Medical Clearance and Health Responsibility

I certify that, to the best of my knowledge:

I am physically capable of participating in exercise activities.
I have not been advised by a physician or healthcare provider to avoid exercise.
It is my responsibility to consult a physician before beginning an exercise program if I have any medical concerns.

I will immediately stop and inform my trainer if I experience pain, dizziness, shortness of breath, or other unusual symptoms during exercise.

Medical Conditions, Injuries, or Limitations (if any)

Acknowledgement of Virtual Fitness Class

I understand that virtual personal training sessions and client evaluations provided by Exercise For Longevity LLC may include live video coaching, strength and mobility exercises, cardiovascular activity, balance exercises, and other physical activities.

I understand that participation is voluntary and that these services are intended to support general health and fitness.

Fall Risk and Mobility Acknowledgement

I acknowledge that physical activity carries the risk of falls, especially during balance or mobility exercises.

I am responsible for:

Ensuring my exercise area is free from hazards (loose rugs, furniture, clutter).
Using support or modifications when necessary for stability.
Modifying or stopping any exercise if I feel unsteady, dizzy, or uncomfortable.

I agree to follow all instructor guidance carefully and participate at my own risk. I release Exercise For Longevity LLC, it's owners, its instructors, and affiliates from any liability related to falls, trips, or mobility-related incidents that may occur during participation.

Risks Acknowledgement

I understand that participation in virtual personal training and virtual evaluations offered by Exercise For Longevity LLC involves physical activity, including but not limited to strength exercises, cardiovascular movement, mobility and balance exercises, and stretching.

I acknowledge that, while the instructor provides guidance and instruction, participation in these activities carries inherent risks. These risks may include, but are not limited to:

Muscle strains, bone injuries, joint injuries, or ligament sprains
Cardiovascular complications
Falls, slips, or trips
Dizziness, lightheadedness, or fainting
Other unforeseen injuries or health issues

I voluntarily assume all risks and understand that Exercise For Longevity LLC, its owners, its trainers, and affiliates are not liable for injuries or accidents occurring during virtual sessions.

Participant Responsibilities

I acknowledge that it is my responsibility to exercise within my own limits, modify or skip any movements that cause discomfort, and consult a physician before participating if I have any concerns.

I agree to:

Exercise within my limits
Follow instructor guidance during sessions
Provide accurate health information
Stop and notify my instructor immediately of discomfort or unusual symptoms

Virtual Training Disclaimer

I understand that personal training and evaluations provided by Exercise For Longevity LLC may be conducted virtually through online platforms such as live video sessions.

I acknowledge that Exercise For Longevity LLC is not responsible for:

Technical issues, interruptions, or outages
Device malfunctions
Any issues that may limit my participation in a session

I acknowledge that when participating in virtual personal training and virtual evaluation I am responsible for ensuring that I have an appropriate and safe exercise environment, including adequate space, appropriate flooring, and the safe use of any exercise equipment.

I understand that the instructor cannot physically supervise my environment or movement during a virtual session and therefore cannot guarantee my safety.

I agree to participate at my own risk and to modify or stop any exercise if I experience pain, discomfort, dizziness, or other unusual symptoms.

Technology Disclaimer

I understand that virtual classes rely on internet and technology services which may occasionally experience interruptions or technical issues.

I agree that Exercise For Longevity LLC is not responsible for technical issues such as internet outages, platform interruptions, or device malfunctions that may affect my ability to participate in a session.

Liability Waiver and Release

In consideration for participating in virtual personal training and virtual evaluations provided by Exercise For Longevity LLC, I voluntarily release and hold harmless Exercise For Longevity LLC, its owners, trainers, and affiliates from any claims, demands, or damages arising from my participation, except in cases of gross negligence.

Payment Policy

I understand that payment for virtual personal training and virtual evaluations must be made prior to or at the time of the scheduled session unless otherwise agreed upon.

Sessions or packages are non-transferable and may have expiration dates unless otherwise specified by Exercise For Longevity LLC.

Fees are non-refundable except where required by law.

Cancellation Policy

I understand that at least 24 hours notice is required to cancel or reschedule a session.

Sessions cancelled with less than 24 hours notice may be charged as a completed session. Missed sessions may not be refunded but may be rescheduled at the discretion of Exercise For Longevity LLC.

I understand that Exercise For Longevity LLC is not in control of my technology and if I have technological issues during a class, I will not be refunded.

Accuracy and Agreement

Check all that apply:*

I certify that the information I have provided is accurate and complete.

I understand the risks of participating in virtual personal training sessions and evaluations.

I agree to abide by the payment and cancellation policies.

I have read, understand, and accept all sections of this agreement.

Signature*

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