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Dakota Personal Training & Pilates

Dakota Personal Training & Pilates, Personal Training, Semi-Private Training, Pilates, Upper West Side, Logo
Guest Waiver & Brief Medical History

    First Name (Required)

    Last Name (Required)

    Trainer Name (Required)

    Phone Number (Required)

    Email Address (Required)

    Address 1 (Required)

    Address 2

    City (Required)

    Zip/Postal Code (Required)

    State (Required)

    Has your doctor ever said you had heart trouble?
    YesNo

    Do you frequently have pains in your heart and chest?
    YesNo

    Do you often feel faint or have or spells of severe dizziness?
    YesNo

    Has your doctor ever said your blood pressure was too high?
    YesNo

    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?
    YesNo

    Is there any good physical reason not mentioned here why you should not follow an exercise program even if you wanted to?
    YesNo

    Are you over the age of 65 and not accustomed to vigorous exercise?
    YesNo

    Have you traveled in the past 14 days?
    YesNo

    Are you running a fever?
    YesNo

    Do you have a cough not related to allergies?
    YesNo

    Do you have an upset stomach?
    YesNo

    Have you tested positive for COVID-19 in the past 48 hours?
    YesNo

    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.

    ** We must be given 24 hours’ notice for any and all cancellations,
    if not you will be charged for your session. **

     

    Do you accept the terms and conditions