September 9, 2015 jpresident Registration If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Pre-Training Questionnaire Please take a few minutes to carefully fill out this health form and click "submit" at the bottom of the page. For your privacy, the information you provide in response to these questions is strictly confidential. Thank you! My Basic Information First Name * Last Name * Birthday * Address 1 * Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Timor-Leste (East Timor) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia, South Sandwich Islands South Sudan Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Email * Cell Phone Work Phone Occupation Emergency Contact First Name * Emergency Contact Last Name * Emergency Contact Phone Number * Emergency Contact Relationship * My Health, Fitness and Physique Goals I'd like to... Tone muscleBuild muscleLose 5-15 lbsLose 15+ lbsGain confidenceLose bodyfatIncrease strengthImprove endurance / cardiovascular healthShape my coreImprove balanceLearn how to make healthier food choicesKnow exactly what I should be eating/drinkingShape bodyImprove flexibilityDecrease aches/painsRelieve stressImprove energyTrain for an event (weddingTrain for a sportLearn new exercisesImprove cholesterolImprove blood pressureImprove blood sugarGet a personalized exercise prescriptionImprove my lifestyle choices How do you feel about the way you look? Fantastic! I'm comfortable in my skin I'm not comfortable with my body It makes me very unhappy I feel embarrassed I don't like thinking about it Please identify which sentence(s) describe your reasons for exercising: I want to feel better about myself I want to have a body that I'm proud of I want to look good for other people I want to feel more fit I want to be healthy for the long term I'm an athlete/I'm competitive What parts of your body are you unhappy with? How do you feel about your current fitness level? Great! I'm satisfied It needs some work I'm pretty unhappy about it Have you tried and failed with exercise regimens and/or diets in the past? Yes No What days of the week and times are you available to meet for training? How many hours a week do you spend on your health/physique? (Consider time spent going to the gym, classes, hiking, reading articles, etc.) Have you worked with a trainer before? No Yes Yes If you are training for a sport or event, please share what they are: On a scale of 1 to 10, how committed are you to working on your health / figure? (1 is not at all, 10 is entirely committed) 1 2 3 4 5 6 7 8 9 10 What are you looking for in a trainer? My Fitness Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, neck, etc)? Yes No If yes, please explain the injury and treatment: Have you ever had any surgeries? Yes No If yes, please explain: Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? Yes No If yes, please explain: Are you currently taking any medication? * Yes No If yes, please tell list your medication and corresponding health issue. How many times a week do you drink alcohol? * None Once Just the weekends Three to four times Almost every day If yes, on each occasion, how many drinks do you consume on average? One to two Three to five Five or more Do you currently smoke? Yes No If not, have you smoked before? Yes No If you answered yes to either question, how many cigarettes on average did/do you smoke? Are you pregnant? * Yes No If yes, what trimester? If no, have you ever been pregnant? Are you currently experiencing or have you gone through menopause? Yes No If yes, please list any concerns you might have: Accuracy of Information Provided I hereby acknowledge that the information I have provided in this health questionnaire and release form is truthful and correct, and that I have no medical conditions that should prevent me from exercise against the advice of any of my doctors or medical professionals. Signature (type full name) * Date Confirm Birth Date * Parent/Guardian Consent Acknowledgement and Consent: I understand that President Productions/President Training Systems/DAE/ENL Fitness uses local recreational facilities and understand that all centers are operated by separate governing bodies. From time to time, the use of these facilities will have to be changed to accommodate their programs. The upkeep and maintenance of these facilities are beyond the control of President Productions/President Training Systems. However, we will address any unsafe conditions and make the operators aware of this, we will not utilize any courts that are unsafe. President Productions will be authorized to utilize any photographs or videos of my child that may be taken during involvement in their training activities. I consent to such uses and hereby waive any rights of compensation. Waiver of Liability & Disclaimer: In consideration of my child’s membership, and any participation in the activities and special programs or events of President Productions/President Training Systems/DAE/ENL Fitness on behalf of myself and my child and any heirs or assigns of myself or my child, waive, release, and agree to defend and hold harmlessPresident Productions/President Training Systems/DAE/ENL Fitness, and its sponsors, staff members, board of directors, and any other affiliated persons and/or vehicle drivers from any and all claims, injuries, death, damages, and demands arising or in any way resulting from or connected to any training-related event, activity, program, or property. I attest and verify that I have full knowledge of the risks involved in basketball training-related events, activities, programs, and properties and that I will, on behalf of the my child, assume and pay any medical or emergency expenses. I further acknowledge that my child is physically fit to participate in the programs or other activities of President Productions/President Training Systems. Emergency Authorization: I, the undersigned, as parent/guardian of my child, hereby authorize the staff of President Productions/President Training Systems/DAE/ENL Fitness, its sponsors, and vehicle drivers as my agents to consent to medical, surgical, dental examination or treatment of my child. In case of emergency, I hereby authorize treatment or care at any hospital or by any licensed medical personnel. NOTE: YOUR SIGNATURE BELOW ACKNOWLEDGES THAT YOU HAVE READ AND ACCEPT THE POLICIES/CONDITIONS OF PRESIDENT PRODUCTIONS/PRESIDENT TRAINING SYSTEMS AS DESCRIBED ABOVE. Parent/Guardian’s Signature (type full name) Date