Just fill in the applications below and our team will contact you.
Data Collection Sheet
Date of Birth*
All answers are required*
1. What is your current occupation?*
2. Does your occupation require extended periods of sitting?*
3. Does your occupation require extended periods of repetitive movements?*
4. Does your occupation require you to wear shoes with a heel (dress shoes)?*
5. Does your occupation cause you anxiety (mental stress)?*
1. Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)?*
ReadingGardeningWorking on carsExploring the internetOther
1. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?*
2. Have you ever had any surgeries? (If yes, please explain.)*
Yes, please explain:
3. 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? (If yes, please explain.)
Yes, please explain:
4. Are you currently taking any medication? (If yes, please list.)*
Yes, please list:
Motivation / Change
1. On a scale of 1-10 how hard do you want to be pushed?*
2. Have you ever worked with a trainer before?*
3. What did you like most about your trainer?
4. What areas of your body do you want to improve the most?*
5. When is the last time you exercise for an hour?*
6. What type of exercise was it?*
Physical Activity Readiness Questionnaire (PAR-Q)
1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *
2. Do you feel pain in your chest when you perform physical activity? *
3. In the past month, have you had chest pain when you were not performing any physical activity?*
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *
7. Do you know of any other reason why you should not engage in physical activity? *
If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
RELEASE AND WAIVER OF LIABILITY FORM
Danielly’s Fitness LLC
855 Hayes St, Sonoma, CA. 95476
Name of participant*
I understand that Danielly’s Fitness LLC will provide personal physical training services and recommendations relating to those services, including suggesting diet changes and recommending consultations with physicians, which may be in person or online through the Company’s website or by directing you to a third person’s website.
I understand that Mind Body Transformation is a program of Danielly’s Fitness LLC and is not offered as a substitute for professional mental health care or medical care and is not intended to diagnose, treat or cure any mental health or medical conditions. I also understand Danielly’s Fitness LLC is not acting as a mental health counselor or a medical professional.
I understand and agree that I am fully responsible for my well-being during my coaching sessions, and subsequently, including my choices and decisions. I understand that coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I understand that all comments and ideas offered by my life coach are solely for the purpose of aiding me in achieving my defined goals. I have the ability to give my informed consent and hereby give such consent to my coach to assist me in achieving such goals.
I represent that I am 18 years of age or older and legally capable of entering into this agreement. I further agree to cooperate and conform to the directions, policies, rules, and instructions of Danielly’s Fitness LLC personnel responsible for the services that will be provided.
I understand that physical exercise can be strenuous and subject to the risk of serious injury. I have had a physical examination from a doctor and I am not aware of any medical condition which would render it inappropriate for me to participate in any program involving physical exercise and a change of diet and I assume the risk of any physical, mental, or medical condition I may have or that may result as a consequence of participating in any of the foregoing activities.
If I receive any recommendations for changes in diet including the use of food supplements and weight reduction products, I will consult with a physician prior to undergoing any dietary or food supplement changes. I agree that I am voluntarily participating in these activities and assume all risks of injury, illness, or death.
As consideration for my being permitted to participate in the above-referenced programs and receive the services of Danielly’s Fitness LLC, I agree to forever release, discharge, and hold harmless from any legal and/or other liability and agree not to sue the Company or its employees, agents, representatives, members, shareholders, officers, directors, coordinators, staff, parents, volunteers, assigns, heirs, next of kin, and/or estates arising out of any liability, costs, fees, damages, judgments, injuries, physical or psychological, death, or property damage resulting from my participation in the program or from the receipt of any services provided by the Danielly’s Fitness LLC whether or not such liability, costs, fees, damages, injury, or death was caused by the negligence, active or passive, or default of the Danielly’s Fitness LLC.
I understand that my participation in the above-described program and activities involve risks of injury, including, but not limited to, falls, loss of control, collisions, accidents, and physical and/or psychological injuries and I agree to assume all risks and all liabilities connected with the above-described program and activities.
I understand and agree that this Release and Waiver of Liability form relates to and binds the undersigned, including my family, heirs, assigns, agents, legal representatives, administrators, trustees, estates, and any other interested person(s) or entity. If any portion of this Release and Waiver of Liability shall be deemed to be invalid, then the remainder of the unoffending provisions shall remain in full force and effect. I agree that the provisions of this document may be assigned by Danielly’s Fitness LLC to any successor business that undertakes to provide the programs and activities to the Participant as specified herein.
I have read the Release and Waiver of Liability form and fully understand its terms, and understand that I have given up substantial rights by signing it and have signed it freely and voluntarily and I intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Participant´s Name / Signature*
I have read and agree to the terms presented in Release and Waiver of Liability Form* (required)
24 HOUR CANCELLATION POLICY
Danielly’s Fitness has a 24-hour cancellation/rescheduling policy. If an appointment is missed, cancelled, or changed within less than a 24-hour notice, there will be a charge. While we realize that changes can occur, our trainers cannot absorb the financial responsibility of last-minute cancellations. Our business reserves specific times for each client affording individual care. In fairness to all clients, this policy is in effect regardless of the reason for the cancellation. .
By signing below, you acknowledge that you have read and understand the Cancellation Policy for Danielly’s Fitness.
I have read and agree to the terms presented in the 24 Hour Cancellation Policy*(required)