To book your free Assessment just fill out the Assessment sheet.
Print and bring your completed Form and signed waiver to your appointment.
Please Call to let Jim know when it is a good time to reach you 415-897-9287
Name:
Age Height Weight
Occupation:
Street:
City:
State:
Zip:
Home Phone
Work Phone
Fax Number
E-mail
my current fitness level as a (1-10), ten being high.
I was referred by
My main goal is to ____________________________________________________________________.
Emergency Contact and phonenumber_______________________
I will be paying by: (circle one) Check Money Order/Cashiers Check.
Price of program $ _____
If paying by check, please make payable to Hit The Hill!
Waiver must be signed prior to participation.
MEDICAL HISTORY
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
3. Do you have a seizure disorder (epilepsy)? Yes No
4. Do you have diabetes Adult or Juvenile? Yes No , List Medications:
5. Have you ever been found to be anemic (low blood count)? Yes No
6. Do you have High Blood Pressure (hypertension)? Yes No
List Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease: Yes No
Lung Disease: Yes No
Kidney Disease: Yes No
Liver Disease: Yes No
8. Do you have asthma? Yes No
List Medications:
9. Have you ever had a severe neck injury?
Describe:
10. Have you ever been knocked out?
Describe:
11. Do you wear glasses or contact lenses? Yes No
12. Have you had a broken bone or fracture in the past 2 years?
Describe:
13. Have you ever injured your back?
Describe:
14. Do you have back pain?
Never Seldom Occasionally Frequently with vigorous exercise or heavy lifting
15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?
Describe:
16. Do you have other physical conditions which cause pain?
Describe:
17. Detail any surgical procedures:
18. What are your goals for the next three months?
19. Have you had your body fat tested?
If yes, what percent is it?
20. Are you training for a specific event?
If yes, explain:
NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!
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Consent & Release of Liability
In consideration for being permitted to participate in the Hit the Hill personal training sessions and/or
related fitness activities (individually and collectively, the “Activity”) as well as the benefits that I will
derive from my participation in the Activity, I hereby represent and agree as follows:
1. Representations . (a) I am physically fit and able to participate in the Activity; I am in good health,
and I am unaware of any medical condition which might make my participation inadvisable. (b) I have
no pre-existing physical limitation or condition which may be aggravated or harmed by my
participation in the Activity. (c) I acknowledge my responsibility to acquire and maintain, during the
period of each Activity, health insurance coverage sufficient to provide for all medical, vision or dental
services and/or equipment required to treat any injury related to my participation in the Activity. (d) I
hereby represent that I have such insurance coverage in effect as of the date set forth below. I
understand that Hit The Hill! carries no dental, medical, vision or other health insurance for any
participant and that I am solely responsible for securing my own health insurance coverage. (e) I
acknowledge that I have had the opportunity to ask HitThe Hill!’s representatives any questions that I
may have about the Activity (including but not limited to the various activities that comprise the
Activity) that I believe are necessary in order to decide whether I am able to participate in the
Activity and make the above representations. I represent that all such questions have been answered
to my complete satisfaction. In connection with the above, I further represent that I have had an
opportunity to inspect the equipment to be used in the Activity prior to my participation in it and,
based upon my inspection, I have found all equipment to be in good condition and in proper working
order.
2. Assumption of Risk . I acknowledge that my participation in the Activity carries with it certain
inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I understand
that the specific risks can and do vary from one activity to another and that these risks range from (a)
minor injuries such as scratches, bruises, and sprains, to (b) major injuries such as eye injury or loss of
sight, joint or back injuries, disfigurement, heart attacks, and concussions to (c) catastrophic injuries
including paralysis and death.
3. Release of Liability . I, on behalf of myself, heirs, assigns, personal representatives and estate
hereby release, forever discharge and covenant not to sue Hit The Hill!, their owners, managers,
members, officers, employees, partners, sponsors, volunteers, agents, advisors and insurers (the
“Released Parties”) from any and all liability from all claims, actions, suits or other proceedings
resulting in personal injury, including death, accident, illness or property damage, I may suffer or
sustain, regardless of fault, arising from or in connection with, my participation in the Activity, the
equipment used during the Activity (whether provided by Hit The Hill!, a third party or myself) and the
building or facilities where the Activity was located.
4. Indemnification . I hereby voluntarily release, forever discharge and agree to indemnify, defend and
hold harmless the Released Parties from and against any and all claims, actions, suits, proceedings,
costs, expenses, damages, and liabilities, including attorneys' fees, brought as a result of my
participation in the Activity, the equipment used during the Activity (whether provided by Hit The
Hill!, a third party or myself) and the building or
facilities where the Activity occurred and to reimburse the Released Parties in full for any such
expenses incurred.
5. Name and Likeness . I hereby grant to Hit The Hill!, its licensees, successors and assigns, the right
to photograph and/or videotape me during my participation in the Activity and further grant
Hit The Hill! the right to display, reproduce, use and/or otherwise exploit my appearance, image,
likeness, name and voice in perpetuity and throughout the world, in all media, whether now known or
hereafter devised, and in all forms and formats, for any purpose whatsoever, without compensation,
reservation or limitation. I understand that no photograph, videotape or other material of any kind
needs to be submitted to me for my prior approval or inspection and I hereby release Hit The Hill !, its
licensees, successors and assigns from any and all liability for any actual or alleged distortion of
appearance, image or likeness as depicted in any photograph, videotape or other visual or audio-
visual work resulting from its publication as well as any advertising copy or other printed materials
that may be used in connection therewith or the use to which it may be applied. I agree that any
visual or audio-visual work which depicts me (in whole or in part) shall be owned by Hit The Hill! and
that Hit The Hill! may copyright same. To that end, I hereby assign and transfer to Hit The Hill! all
right, title and interest in and to my appearance, image, likeness, voice as embodied in any audio,
audio-visual or visual work. I agree that Hit The Hill! shall have the sole and exclusive right, title and
possession to all original negatives, videotapes and related materials that may embody My Picture. I
acknowledge that Hit The Hit! is under no obligation to exercise any rights granted herein.
6. Miscellaneous . If any part, article, paragraph, sentence or clause of this consent and release is not
enforceable, the affected provision shall be curtailed and limited to the extent necessary to bring it in
within the requirements of the law, and the remainder of this consent and release shall continue in
full force and effect. This consent and release shall be governed by the laws of the State of California .
All provisions of this consent and release shall survive the termination or expiration of any Activity or
my participation in any Activity contemplated hereby.
I knowingly intend my signature on this consent and release to be a complete defense to any legal or
equitable proceeding that may be brought by me, or any person on their own or on my own behalf, for
any personal injury, including death, accident, illness or property damage, including theft, I may suffer
or sustain as a result of my voluntary participation in the Activity, and further intend this consent and
release to be a complete and total release of liability for all negligent acts, failure to act, or breaches
of duty owed to me, which result in my personal injury, accident, illness and/or property loss as a
result of my participation in the Activity, the equipment used during the Activity (whether provided by
Hit the Hill!, a third party or myself) and the building or facilities where the Activity occurred and to
reimburse the Released Parties in full for any such expenses incurred.
I represent that I am 18 years of age or older, that I am legally competent and capable of executing
this consent and release on my own behalf, that I have read the foregoing and have made a conscious
decision to sign it of my own free will. I further represent that I understand and agree to the terms of
this consent and release and have received a copy of same.
____________________
Signature
____________________
Printed Name
____________________
Date
Hit The Hill
Recruitment
For more information or phone consultation please fill out the short form. To get
started please fill out the long form below then submit. Or Call 415-897-9287
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