New Client Profile | Madison West

Please fill out this new client information sheet that includes your critical data, a PAR-Q Assessment, and your schedule availability

Profile Info

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Gender

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Birthday

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Please enter a valid year after 1900

Address

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Emergency Contact Info

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(we do not contact this person unless there is an emergency)

How did you hear about Orange Shoe?

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What are your fitness goals?

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On a scale of 1 to 10, how passionate are you about achieving your fitness goals?

1 2 3 4 5 6 7 8 9 10

What obstacles have you faced in achieving your fitness goals in the past?

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Do you have the support of the people close to you?

Yes No

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After your consultation you will be given 5 complimentary passes for friends, family (or anyone!) to join you for two weeks. Do you prefer us to send these on your behalf or would you like to send them?

You can send them I'll send them

I'll send them

No thanks, I prefer to workout solo

Anything that is important for us to know? Include injuries, limitations, events you are training for - or anything else that you think will be helpful for us to know so that we can best help you achieve your goals.

PAR-Q and You

If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes No

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Do you feel pain in your chest when you do physical activity?

Yes No

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In the past month, have you had chest pain when you were NOT doing physical activity?

Yes No

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Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes No

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Do you have a bone or joint problem that could be made worse by a change in activity?

Yes No

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Is your doctor currently prescribing drugs for your blood pressure or heart condition?

Yes No

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Do you know of any other reason why you should not do physical activity?

Yes No

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If you answered YES to one or more questions:

Talk to your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want- as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

If you answered NO to all questions, you can be reasonably sure that you can:

Start becoming much more physically active - begin slowly & build up gradually. This is the safest & easiest way to go.
Take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.

Even if you answered NO to all questions, you should delay becoming much more active:

If you are not feeling well because of a temporary illness such as a cold or a fever - wait until you feel better.
If you are or may be pregnant - talk to your doctor before you start becoming more active.

Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan. Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons who undertake physical activity. If in doubt after completing this questionnaire, consult your doctor prior to physical activity.

Client Release and Indemnity

By checking the box below to signify agreement with the Terms and Conditions Agreement and/or by attending sessions or otherwise participating in Studio activities, Client hereby acknowledges and agrees that there are inherent risks in exercise and in using the equipment associated with the Studio’s classes or instruction. Client assumes full responsibility for his or her use of the Studio’s facilities and shall indemnify Orange Shoe, Orange Shoe Gym Holdings, Inc. and its shareholders, affiliates, agents and employees, and, with respect to sessions at Orange Shoe off-site, the off-site host, against any and all liability arising out of the use of the facilities. Additionally, Client and his or her guests shall hold the Studio, and, with respect to session at Orange Shoe off-site, the off-site host, harmless from any loss, theft, cost, claim, injury, damage or liability incurred as a result of Studio or off-site use and membership activities.

In the event Client commences an action against the Studio or its shareholders, affiliates, agents or employees and fails to obtain judgment or partial judgment in Client's favor, Client shall be liable to the Studio for all costs and expenses associated with Studio’s defense of the action or any claims on which Client did not prevail, including attorney’s fees and costs.

Your Signature

Enter your name, agree to your digital signature being represented, and enter the date.

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I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.

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By checking YES I agree that the above submitted information is true & agree with the above Terms and Conditions

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Today's Date

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Please enter a valid year after 1900

Training Schedule Availability

Please take a moment to help us create an effective schedule for you by letting us know when you are available to train. Mark the times that you are regularly available to train. Based on availability, we will create a personal training schedule for your approval.

Weekday Availability (Select all times you are available)

Early Morning (Before 9 am) Morning (9am - noon) Early Afternoon (noon - 3pm) Late Afternoon (3pm - 6pm) Evening (After 6pm)

Saturday Availability (Select all times you are available)

Early Morning (Before 9 am) Morning (9am - noon) Early Afternoon (noon - 3pm) Late Afternoon (3pm - 6pm) Evening (After 6pm)

Sunday Availability (Select all times you are available)

Early Morning (Before 9 am) Morning (9am - noon) Early Afternoon (noon - 3pm) Late Afternoon (3pm - 6pm) Evening (After 6pm)

Add any additional info about availability or scheduling that is important for us to know.