Wufoo

Ice Chamber Client Profile Form

Contact Information
Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone * - (###) - ### ####
Cell Phone * - (###) - ### ####
Work Phone - (###) - ### ####
Email *
Web Site
Today's Date * / MM / DD YYYY
Waiver of Liability
I have enrolled in a program of strenuous physical activity including, but not limited to, aerobic exercise, weight training, and the use of various aerobic-conditioning machinery offered by Ice Chamber – Athletic Performance Training (referred to, from this point forward, as Ice Chamber). I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit my participation in the exercise program.

In consideration of my participation in Ice Chamber’s exercise program, I, for myself, my heirs and assigns, hereby release Ice Chamber (its agents, officers, principals, employees and owners), from any claims, demands and causes of action arising from my participation in the exercise program.

I fully understand that I may injure myself as a result of my participation in Ice Chamber’s exercise program and I, hereby release Ice Chamber from liability now or in the future including, but not limited to, heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries, and any other illness, soreness, injury, or even death, however caused, occurring during or after my participation in the exercise program. *
I accept and agree to the tems and conditions of this waiver.

Please print and sign a copy of this completed form and return it to us on your first day of training.
Health / Fitness Profile
Date of Birth * / MM / DD YYYY
Age *
Sex *
Male Female
Fitness Background / Athletic History *
Fitness / Athletic Goals *
Risk Assessment
1. Have you ever had any form of heart disease? *
Yes No
2. Do you ever experience shortness of breath or chest pains? *
Yes No
Do you have any of the following conditions?
1. High Blood Pressure *
Yes No
2. High Cholesterol *
Yes No
3. Smoking Habit *
Yes No
4. Diabetes *
Yes No
5. Family History of Heart Disease *
Yes No
6. Currently Taking Medications *
Yes No
Please describe any pains or injuries you have in the following areas:
1. Knees *
2. Lower Back *
3. Neck / Shoulders *
4. Hip / Pelvis *
Other Areas *
Please indicate the program(s) you are interested in. *
Morning Bootcamp Personal Training Core Performance Group Fitness Kettlebell Lifting ReBoot Sport Performance Training
Please indicate the best times/days you are available for your Starter Pack or Personal Training sessions. *
Do Not Fill This Out

Wufoo

Ice Chamber Client Profile Form

Contact Information

Waiver of Liability

Health / Fitness Profile

Risk Assessment

Do you have any of the following conditions?

Please describe any pains or injuries you have in the following areas: