Online Personal Training Enrollment Form

FOR CREDIT CARD ORDERS ONLY

To order by mail print and fill out this form in full, then mail it with your check or money order to:
Paul Becker
PO Box 2471
Hillsboro, OR 97123
** All information is considered confidential, and will only be used
for the purposes of designing a training and nutritional program. **

1. Personal Information

Name and home address:

E-mail address:

2. Your Goals

What are your fitness goals? (Be specific)

3. Statistics/Measurements

Sex: Age:

Height: Weight:

Neck: Chest (normal):

Chest (expanded): Upper arm (flexed):

Upper arm (straight):

Wrist (around the protruding bone):

Forearm:

Waist (around the belly button):

Hips: Thigh:

Knee: Calf:

Ankle:

4. Fitness, Nutrition and Lifestyle Profile

What is your weekly schedule like? (Be specific, include work, school, activities, family responsibilities, hobbies, sleep, etc.)

Give a description of your eating habits for a typical day (Be specific, include what you eat, drink, amounts, times, any supplements, etc.)

Where do you train and what equipment is available to you?

What is your current routine? (Be very specific, include days a week, exercises, weight used, sets, reps, etc.)

Do you have any Bone, Joint, Ligament or Tendon Problems? (If yes, be specific and include any exercises that cause pain or irratation and any exercises that you can perform that do not cause problems)

Do you have any medical conditions?

Are you taking any medications/drugs?

Any other information you feel may apply?

5. Agreement

Paul,

I want to achieve my goals and am ready to get started with your online personal training; please design a custom training and nutritional plan based on my specific needs and lifestyle. I understand that you will personally guide me every step of the way by answering any questions I have and by updating my training/diet program when needed based on the feedback I give you. I promise to follow your advice and stick to the program for the full amount of time I signed up for and that if I'm not 100% satisfied, I can ask for a full Refund.

I also understand that you strongly advise me to check with my doctor before following this or any exercise or dietary program. I realize that your programs are designed to give me the best results for my efforts and that I must work hard in order to get results, and that you are only advising me and will not be with me when I'm training and that you can not be held responsible for any mishap or injury that may occur.

I am over 18 years old and agree to the above conditions, or I am the parent or gaurdian of this person and agree to the above conditions.

Write Name:

Please Sign me up for:

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