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Your info


Emergency Contact


General Health & Nutrition


Weekly Exercise Information

Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 7-day period.












Lifestyle/Professional Activity

How would you rate the activity level of your profession, or what you do during the day? (Non-exercise related)

What are you goals?


Body Type

Which of the following statements best describes you?


Health & Medical Conditions

Check any that apply or describe any onthers

Cancer
Injuries
Other

 


Are you under the care of a physician?

If yes, has your doctor cleared you for physical activity and nutritional guidance?

 


List your allergies to any types or kinds of food

Have you ever been on any type of nutritional program in the past?

If yes, by whom and what did it consist of? Please explain below:

What were your results?


Have you ever had any of the following:

 

Have you recently had:

 

Have you ever had any of the following:

 

If you answered yes to any of the items above, please explain:

Are you currently taking medication for any ailment?

If yes, please list the medications:

 

Please list below everything you eat in one 24 hour period. Be sure to include snacks and beverages, including water. Also, show approximate amounts.













 

List your favorite foods:

List foods you dislike:

Do you smoke?

If yes, how many years have you been smoking and how many per day?

Do you drink alcoholic beverages?

If yes, what kind and how many per day?

 

Please check yes or no for the following questions.

Have you ever been told by a physician that you could not regularly participate in any physical activity?

 

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

 

Is you doctor currently prescribing drugs for your blood pressure or heart condition?

 


 

RELEASE OF LIABILTY - READ BEFORE SIGNING

In consideration of being allowed to participate in any way in the End Results Health and Wellness program, and its related events and activities, I, , acknowledge, appreciate, and agree that:

  • The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist.
  • I knowingly and freely assume all such risks, both know and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation.
  • I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of End Results immediately.
  • I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, herby release, indemnify, and hold harmless End Results Health and Wellness Center, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owner of premises used for the activity, with respect to any and all injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND AND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY

PARTICIPANT’S SIGNATURE
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If you are over the age of 18, you can scroll to the bottom and click Submit.

 

FOR PARENT/GUARDIAN OF PARTICIPANTS OF MINORITY AGE
(UNDER 18 AT TIME OF REGISTRATION)

 

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the releases, and, for myself, my child, and our heirs, assigns, and next of kin. I release and agree to indemnify and hold harmless the releasees from any and all liabilities incident to my minor child’s involvement or participation in the programs as provided above, even if arising from negligence of the releasees, to the fullest extent permitted by law.

PARENT/GUARDIAN'S SIGNATURE
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