If you are a new client please complete the following information. This is required before participating in any activities.

Best way to notify you in the event of schedule changes, cancellations, etc (required)

Have you visited your physician in the last year? (required)

Has your doctor restricted you from any physical activity? (required)

Do you experience any of the following? (check all that apply) (required)
NoneJoint PainTendon painMuscle painAbdominal painKnee painLower back painNeck painShoulder painShortness of breathDizzinessFrequent headaches requiring treatment

Have you lost consciousness in the last 12 months? (required)

Do you have a heart condition? (required)

Do you have Asthma? (required)

Do you have Diabetes? (required)

Do you have High Blood Pressure? (required)

Have you ever been diagnosed with another chronic medical condition? (required)

Has your doctor ever said that you should only do medically supervised physical activity? (required)

Are you currently undergoing treatment from a chiropractor, massage therapist, or physiotherapist? (required)

Have you had major surgery in the past 10 years? (required)

I acknowledge that any fitness activities associated with this program may be an extreme test of my physical and/or mental abilities. I hereby certify that I am fit to participate in any and all such activities and that such determination has been made by a qualified medical professional.

POLICIES

- participants must be aware of their respective physical condition levels and limits. They must understand that there are risks associated with their participation in any of the Fitness and Nutrition programs offered by 10x10.fitness
- All participants must adhere to the rules and policies set forth by all facilities.
- The scheduling and or content of training workouts/fitness classes may be changed on
occasion due to circumstances beyond control. In the event of a schedule change the
instructor will make up the session.
- membership payments are non-refundable – however, if an unavoidable situation arise
which causes you to not be able to partake in the remainder of your sessions please inform
Meghan as soon as possible and the remaining credit can be saved and used at a later date
- once you’ve had a private consultation; should you decide not to take part in the program you
will be refunded your registration fee minus $45 for the consultation.
- Cancelling just before class or no shows will be charged full price, no refund or make ups.
- Fitness Program packages are valid for up to the date specified at the point of purchase

I have read and fully understand the above waiver and release from liability & policies, and I agree to
abide by the terms and conditions set forth therein.

Please type your full name below as your signature to confirm your acceptance of the above waiver and policies (required)