Dakota Personal Training & Pilates
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646.287.6033
Menu
HOME
SERVICES
BLOG
ABOUT US
PRICING & PAYMENT
PRICING
PAYMENT
WAIVER
FAQs
CONTACT US
646.287.6033
Guest Waiver & Brief Medical History
Guest Waiver & Brief Medical History
Name
(Required)
First
Last
Trainer Name
(Required)
Phone Number
(Required)
Email Address
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Has your doctor ever said you had heart trouble?
(Required)
Yes
No
Do you frequently have pains in your heart and chest?
(Required)
Yes
No
Do you often feel faint or have or spells of severe dizziness?
(Required)
Yes
No
Has your doctor ever said your blood pressure was too high?
(Required)
Yes
No
Has your doctor ever told you that you had a bone or joint problem such as arthritis, that has been aggravated by exercise, or might be made worse by exercise?
(Required)
Yes
No
Is there any good physical reason not mentioned here why you should not follow an exercise program even if you wanted to?
(Required)
Yes
No
Are you over the age of 65 and not accustomed to vigorous exercise?
(Required)
Yes
No
Have you traveled in the past 14 days?
(Required)
Yes
No
Are you running a fever?
(Required)
Yes
No
Do you have a cough not related to allergies?
(Required)
Yes
No
Do you have an upset stomach?
(Required)
Yes
No
Have you tested positive for COVID-19 in the past 48 hours?
(Required)
Yes
No
Consent
Do you accept the terms and conditions
Welcome to Dakota Personal Training.com, Dakota Personal Training provides the information, services, products, and programs offered through Dakota Personal Training.com (collectively, “Online Services”) to you subject to the following User Agreement (“Terms of Use”), which may be amended as described below. The current Terms of Use will always be available for your review at Term of Use. By accessing and using the Online Services, you agree to the posted Terms of Use.
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
The undersigned guest agrees to abide by the rules of Dakota Personal Training, including completion of the medical questionnaire.
The undersigned guest agrees that all use of Dakota Personal Training Facilities, services, programs, and classes shall be undertaken at his/her/their risk and Dakota Personal Training shall not be liable for any injuries, accidents, or death occurring to the guest, arising either directly or indirectly out of utilizing Dakota Personal Training facilities, services, programs or classes. The guest, for himself/herself/themself and on behalf of his/her/their executors, administrators, heirs and assigns do hereby expressly release, discharge, waive, relinquish, and covenants not to sue Dakota Personal Training, officers, and agents for all such claims, demands, injuries, damages or cause of action with respect to the use of Dakota Personal Training facilities, services, programs, and classes.
The undersigned guest declares that they have completed the enclosed medical questionnaire as a guest of Dakota Personal Training and that they declare they are physically able to participate in physical activity. The undersigned guest declares that Dakota Personal Training has advised the guest to obtain medical clearance in the event that the answer is YES to any of the medical history questions, or if they are unsure of their physical health. The undersigned guest declares that he/she/they are physically capable of physical activity at Dakota Personal Training.
" Please note we charge for sessions canceled with less than 24 hours notice!!!"
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