Client information form

CLIENT INFORMATION & MEDICAL HISTORY FORM K.O. BOXING, INC.
Name________________________________________(Parent)__________________________
Address________________________________________________________Zip____________
Email address: _________________________________________________________________
Phone #’s__________________________________________Birth Date ___________________
How did you hear about K.O. and what is your primary reason for your visit:)
______________________________________________________________________________
Class enrolling _________________________________________________________________
Please answer the following questions: YES NO

Have you ever had a personal training session? ____ ____

Have you ever taken a fitness class? ____ ____

Have you ever been to a gym? ____ ____

Do you wear contact lenses? ____ ____

Do you wear dentures? ____ ____

Do you have any skin problems or allergies? ____ ____

If yes, please describe____________________________________________________________

Have you ever had surgery? ____ ____

If yes, please describe____________________________________________________________

Have you recently suffered an acute injury? ____ ____

If yes, please describe____________________________________________________________

Do you have varicose veins or blood clots? ____ ____

Do you have arthritis? ____ ____

Do you have any spinal problems? ____ ____

If yes, please describe____________________________________________________________

Do you have fibromyalgia? ____ ____

Do you have cancer? ____ ____

Do you have any blood pressure problems? ____ ____

Are you pregnant? ____ ____

Do you have knee problems? ____ ____

Have you tested positive for a contagious disease? ____ ____

If yes, please describe____________________________________________________________

Do you have any other information the K.O. staff should be aware of before participating in classes?_____ If so, please list on separate paper.

I __________________________________________understand that the training given here is for the sole purpose of exercise, helping to increase my overall health, and helping me to reach my fitness goals. I understand that the K.O. Trainer does not diagnose illness or injury, or any other physical or mental disorder. I fully and forever release, indemnify, waive and discharge K.O. Boxing, Inc., it’s owners and any associated employees or trainers from any and all claims, negligence, demands, damages, or rights of action, resulting from or arising out of my use or intended use of said facilities and the equipment thereof. I expressly discharge, waive, indemnify and release K.O. Boxing, Inc., it’s owners, and any associated employees or trainers form liability arising from K.O. Boxing, Inc., it’s owners, and any associated employees or trainers acts or omissions of negligence.

Signature__________________________________________________Date_______________

REFUND POLICY
I ___________________________________ understand that there will not be a refund in my session fees, monthly dues or semester payments. If I can no longer participate in the program I have enrolled, my fees may be credited per my request to the same course offered on a later date or a different course that K.O. has to offer.
SIGNED ________________________________________________________________DATE___________