Personal Training Consultation Request Form



Research has shown that individuals achieve quicker results and are more committed to an exercise program
when they have one-on-one personal training.  Just complete the form below and you'll already be on your way 
to better fitness and health!  Once you submit your information form, we will contact you shortly to set up your 
free consultation appointment at your convenience. Our service can be general or very specific depending on 
your individual needs. 

Please be honest and candid with your responses. All information provided in this form will be kept in the 
strictest confidence and will not be shared with anyone.

Full Name

Street Address

City State Zip

Home Phone

Mobile Phone

Work Phone

Fax Number

E-mail Address

(Please double-check for accuracy.)

Date of Birth

Sex

Height Feet Inches

Weight lbs.

Body Fat Percentage

Are you a member
of a health club? If yes, where?

Rate your current fitness level 1 through 10
(Choose a number - 1 is the lowest, 10 is the highest)

Please describe your current exercise habits:

My main goal is to: (Type Below)

1.	Are you allergic to any medication (aspirin, penicillin, sulfa, etc.?)
2.	Do you take prescribed medications on a permanent basis?
	If yes, list medications:
3.	Do you have or have you had seizure disorders (epilepsy) at any time?
4.	Do you have Adult Diabetes or Juvenile Diabetes?
5.	Have you ever been found to be anemic (low blood count)?
6.	Do you have High Blood Pressure (hypertension)?
	If yes, list medications:
7.	Do you have or have you ever had Heart Disease?
8.	Do you have or have you ever had Lung Disease?
9.	Do you have or have you ever had Kidney Disease?
10.	Do you have or have you ever had Liver Disease?
11.	Do you have asthma?
	If yes, list medications:
12.	Have you ever had a severe neck injury?
	If yes, please describe:
13.	Have you ever been knocked out?
	If yes, please describe:
14.	Do you wear glasses or contact lenses?
15.	Have you had a broken bone or fracture in the past two years?
	If yes, please describe:
16.	Have you ever injured your back?
	If yes, please describe:
17.	Do you have back pain?

18.	Have you had knee pain in the past two years that has disabled you for longer than a week?
	If yes, please describe:
19.	Do you have other physical conditions which cause pain?
	If yes, please describe:
20.	Any recent surgical procedures?
	If yes, please describe:
21.	What are your goals for the next three months?
	Please describe:
22.	Are you training for a specific event?
	If yes, please explain:

NOTICE: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program!

This release is entered into between the undersigned, Val Strang�s Burn Boot Camps, LLC, its officers, affiliates and executors. The purpose of, Val Strang�s Burn Boot Camps, LLC, is to provide fitness instruction and coaching for various levels of athletes/individuals. The undersigned individual hereby acknowledges that the following was explained to them and/or agrees to the following:

1. Acknowledges that Val Strang�s Burn Boot Camps LLC, Valeri Strang or any affiliated staff members are not physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.

2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves. However, Val Strang�s Burn Boot Camps, LLC, Valeri Strang or any affiliated staff member does not guarantee that either good or bad will occur, nor guarantees that the training advice given by them will produce good or bad results.

3. Acknowledges that the undersigned has been told that if they feel fatigued, feel pain or feel out of the ordinary in any way, either related to training, or otherwise, that the undersigned should contact a physician immediately.

4. Acknowledges that personal training, boot camps, martial arts, kick boxing, running, weight training, obstacle courses, and any other related activities are an extreme test of one's mental and physical limits and carry with it a potential for damage or loss of property, serious injury and/or death. Also, that the undersigned assumes all risks of participating in these types of events/activities. It is also agreed by the undersigned that they are fit, and that they have a regular medical physician that they can contact regarding any medical problems that they might develop. The undersigned expressly waives, releases and discharges liability or liability charges of any kind against, Val Strang�s Burn Boot Camps, LLC, Valeri Strang, or any affiliated staff member. The undersigned also agrees not to bring litigation or suit of any kind or dimension as a result of any liability of death, disability, or personal injury suffered by the undersigned. The undersigned also agrees to bring no action of any kind against, Val Strang�s Burn Boot Camps, LLC, Valeri Strang, any affiliated staff members either jointly or severally, or the owners, or members of any affiliated training or Boot Camp site or property, as a result of the undersigned participating in Val Strang�s Burn Boot Camps, LLC and/or training events or for any reason whatsoever.

The Undersigned agrees that this is the full agreement between the parties. The Undersigned also agrees that Val Strang�s Burn Boot Camps, LLC, Valeri Strang, any affiliated staff member, or anyone else has not verbally contradicted any of the Terms of this release and that the undersigned has read and entered into this agreement free and voluntarily without force or or coercion.

If you were referred to Burn Boot Camps by a person, please type their name below:

If you found Burn Boot Camps by another source, please let us know: (Magazine Ad, Article, Flyer, etc.)

Your privacy is very important to us. All information provided will be treated as confidential. The information will not be disclosed to third parties or other government agencies, unless required by state or federal law.

I have read and agree to this Release and consent to submit it electronically. Clicking the "Submit" button is my electronic signature. I understand that if I do not agree to these terms, I should refrain from using this form.

(Please click "submit" only once to avoid accidentally duplicating your registration.)