Fitness Fore Golf Registration | Progressive Elite Training, Penticton

Register online for Fitness Fore Golf

Name:

Email:

Address

City

Province/State

ZIP

Country

Profession

Date of Birth

Home Phone

Work Phone

Cell Phone

I rate my current fitness level as a (1-10), ten being high

How did you hear about us?

Please specify publication / website / friend or other referral

This is my first training

yes no

How often do you golf?

What are your goals for your golf game?

Do you experience any pain during your game of golf?

yes no

Do you presently have any golf injuries?

yes no

If you answer yes please list.

Do you have your doctors permission to take part in this program?

yes no

Name of Emergency Contact

& Phone Number

Choose your Package/Price

all prices include GST

Note: The initial consultation costs are $26.25 (tax included), they will be added to the package price.

Form of payment

1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?

yes no

List medications you are allergic to:

2. Do you take any prescribed medication on a permanent or semi-permanent basis?

yes no

List prescribed medications:

3. Do you have a seizure disorder (epilepsy)?

yes no

List epilepsy medications:

4. Do you have diabetes Adult or Juvenile?

yes no

5. Have you ever been found to be anemic (low blood count)?

yes no

6. Do you have high blood pressure (hypertension)?

yes no

List high blood pressure medications:

7. Do you have or have you ever had the following diseases?

Heart disease

yes no

Lung disease

yes no

Kidney disease

yes no

Liver disease

yes no

8. Do you have asthma?

yes no

List asthma medications:

9. Have you ever had a neck injury? (if yes, describe)

10. Have you ever had a shoulder injury?
If yes, is there any residual pain and are you receiving therapy?

11. Have you ever been knocked out?

12. Do you wear glasses or contact lenses?

yes no

13. Have you had a broken bone or fracture in the past 2 years?

14. Have you ever injured your back?

15. Do you have back pain?

16. Have you had knee pain in the past 6 months that has disabled you for longer than a week?

17. Do you have other physical conditions which cause pain?

18. Detail any surgical procedures in the past 6 months:

19. Are you training for a specific event? If yes, explain:

Before starting any fitness/health/nutrition program it is wise to seek your doctors advice.

RELEASE FORM AND LIABILITY WAIVER. PLEASE READ, CHECK THE BOXES AND SIGN BELOW.

This release is entered into between the undersigned and Progressive Elite Training, its officers, subsidiaries affiliates, and executors in addition to the city of Penticton. The purpose of Progressive Elite Training is to provide fitness instruction and coaching for various levels of athletes/individuals

The undersigned hereby acknowledges that the following was explained to me and or agree to the following:

acknowledges that Sheila Kamaraus is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.

exerciser hereby stipulates that he/she is physically sound and that he/she has approval to proceed with a routine of exercise.

LIMITATIONS OF EXERCISE IF ANY: it is further expressly agreed that all strength training, cardiovascular exercise, or any other exercise shall be undertaken by me at my sole risk and that Sheila Kamaraus her agents or employees shall not be liable to me for claims, demands, injuries, damages, actions or causes of action whatsoever, to my person or property arising out of or connected with the use by me of the services provided and of the premises where the same is located . I do hereby expressly forever release and discharge Sheila Kamaraus and her agents or employees from all such claims, demands, injuries, damages, actions or causes of action, from all acts of active or passive negligence on the part of Sheila Kamaraus and her agents or employees.

Decide.Commit.Succeed.