IS MY fit with myia “your Fit”?

complete the form below

your journey starts today.

Name

First Name

Last Name

Phone

(###)

###

####

What Are You Interested In ?

Have you ever had a Personal trainer?

Have you ever had a Nutrition Coach?

On Scale of 1-5 How Active are you?

(1 being “I’m a couch potato” 5 Being “Let’s break a sweat”.)

Using a scale of 1 to 5, would you be able to exercise for 45 minutes for 3 days this coming week?

(1 being “there’s no way” and 5 being “definitely will do”)

Have you tried anything previously to make progress towards your goals?

Explain if you marked 'yes' above.

What, specifically, has stopped you in the past from reaching your goals?

Do you have any physical restrictions or disabilities?

Explain if you marked 'yes' above.

Has a physician placed you on any physical restrictions?

Explain if you marked 'yes' above.

Do you currently have or has a physician ever placed you on any dietary restrictions?

Explain if you marked 'yes' above.

Do you have any allergies?

Explain if you marked ' yes' above

What would be your #1 Goal?

How would you like us to contact you?

When is the best time to contact you

Hour

Minute

Second

LIABILITY WAIVER TERMS & CONDITIONS

THIS AGREEMENT APPLIES TO PERSONAL INJURY, WHICH I UNDERSTAND MAY ARISE DUE TO MY VOLUNTARY PARTICIPATION IN EXERCISE ACTIVITIES, AND ANY AND ALL CLAIMS RESULTING FROM PERSONAL BODILY INJURY WHILE UTILIZING THE SERVICES OF MY MY FIT WITH MIA, HEREIN REFERRED TO AS MFWM; I FULLY UNDERSTAND THAT I MAY INJURE MYSELF AS A RESULT OF MY PARTICIPATION IN THE FITNESS PROGRAM OF MFWM. INJURIES MAY INCLUDE, BUT ARE NOT LIMITED TO, HEART ATTACKS, DEATH, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEAT PROSTRATION, KNEE/LOWER BACK/FOOT INJURIES, AND ANY OTHER ILLNESS, SORENESS, OR INJURY, HOWEVER CAUSED, OCCURRING DURING, OR AFTER, MY PARTICIPATION IN THE FITNESS PROGRAM OFFERED, UNLESS CAUSED BY A TRAINER'S RECKLESSNESS OR INTENTIONAL MISCONDUCT. IN WHICH THE TRAINERS WOULD BE AT FAULT FOR THEIR RECKLESSNESS OR INTENTIONAL MISCONDUCT. IN CONSIDERATION OF MY PARTICIPATION IN MFWM FITNESS PROGRAM, I, FOR MYSELF, MY PERSONAL REPRESENTATIVES, ADMINISTRATORS, HEIRS AND ASSIGNS, HEREBY HOLDS HARMLESS MFWM, ITS BOARD, EMPLOYEES AND AGENTS, FROM ANY CLAIMS, DEMANDS, AND CAUSES OF ACTION, TO INCLUDE REASONABLE LEGAL EXPENSES AND ATTORNEY'S FEES ARISING FROM MY PARTICIPATION IN THE FITNESS PROGRAM, UNLESS CAUSED BY THE TRAINER'S RECKLESSNESS OR INTENTIONAL MISCONDUCT. IN WHICH THE TRAINER HIM/HERSELF WOULD BE AT FAULT. I HEREBY RELEASE MFWM, ITS BOARD, EMPLOYEES AND AGENTS, FROM ANY LIABILITY NOW OR IN THE FUTURE FOR ANY INJURY THAT I MAY SUSTAIN AS THE RESULT OF PARTICIPATION IN MY TRAINER'S FITNESS TRAINING PROGRAMMING.