Registration

Fitin6 Registration

Call 509-869-4800 with any questions.
Please make checks payable to: The Body Clinic
If printing off and mailing in your registration, please send check or credit card info to:
The Body Clinic
Attn:Fitin6
Po Box 30046
Spokane, WA 99223

Or you may fax registration to 509-443-2606

Full payment must be received before the first day of the program.

Visa/Mastercard _______________________________________ Exp________ Vcode_____


Name:
Date of Birth:
Street:
City:
State:
Zip:
Date:
Home Phone:
Work Phone:
email:
Emergency Contact name and number:
Occupation:
I was referred by:
I rate my current fitness level at (1-10):
I can run a mile in (minutes):
My Goal Is To:
	I understand there is no refund policy
	I will remember to set my alarm and be at set location at designated time
	I will be dedicated to this program and give my very best
	I will have FUN!
	Medical History
Do you take prescription medication?:
Are you allergic to any medications?:
What is the date of your last physical exam?:
Do you have a seizure disorder?:
Do you have diabetes?:
Are you anemic?:
Do you have high blood pressure?:
Do you have: Heart disease, Lung disease, Kidney disease or Liver disease?:
Do you have asthma?:
Have you ever had a neck injury?:
Have you ever been knocked unconscious?:
Do you have back pain?:
Have you had knee pain in the last 2 years that has disabled you for longer than 2 weeks?:
Do you have any other physical conditions, which cause pain?:
Have you had a broken bone or fracture in the last 2 years?:
Have you ever injured your back?:
What are your goals for the next six weeks?:
Are you training for a specific event?:
What do you think your timed mile will be?:
How much have you been running in the last month?:

After you have submitted the above form, please pay here if you are not mailing in your payment.

Release: This release is entered into between the undersigned and The Body Clinic, LLC, it's officers, affiliates, and executors in addition to the City of Spokane and the County of Spokane. The purpose of the Body Clinic, LLC is provide fitness education and coaching for various levels of athletes/individuals.

The undersigned hereby acknowledges that the following was explained to me and/or agree to the following:
1. Acknowledges that Danna Snow and Brittany Wonsick are not physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.
2. Acknowledges that Brittany Wonsick will provide fitness instruction and coaching to the undersigned, but that Brittany Wonsick does not guarantee neither good or Bad results.
3. Acknowledges that the undersigned has been told if they feel tired, feel pain or feel out of the ordinary in any way either related to your training, or otherwise, that the undersigned should contact a physician at once.
4. Acknowledges that the undersigned will not hold the Body Clinic, LLC, Fitin6, Brittany Wonsick, Danna Snow or any of it's affiliates liable for injury, loss of work, or death.
5. Acknowledges that the undersigned assumes the risk of participation in fitness training, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind , Brittany Wonsick for the undersigned participating in said sporting events and/or training for said sporting events.

The undersigned agrees that this is the full agreement between the parties, that Brittany Wonsick, nor anyone else has not verbally contradicted any terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion.

Name__________________

Signature___________________

Date__________________