Participant's Name *

First Name

Last Name

Telephone *

(###)

###

####

Name of Parent or Legal Guardian

First Name

Last Name

Name of Emergency Contact *

First Name

Last Name

Telephone *

(###)

###

####

I understand that I must give 24 hours minimum advanced notice for any cancellations or rescheduling of appointments. If I do not do so, I agree to pay in full for the time I reserved. *

I agree

Signature of Participant or Legal Guardian *

First Name

Last Name

Today's Date *

MM

DD

YYYY

I understand that entering my name above constitutes the legal signing of my name. *

I agree

Participant's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone *

(###)

###

####

Physician's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone *

(###)

###

####

To the best of my knowledge, the information I have provided is accurate. I will agree to inform my trainer of any changes in my health status. I acknowledge that I have no expectation of privacy in the medical information disclosed above and that Succeed, LLC has no responsibility or duty to maintain this information as confidential and private. *

I agree

Signature of Participant or Legal Guardian *

First Name

Last Name

Today's Date *

MM

DD

YYYY

I understand that entering my name above constitutes the legal signing of my name.

I agree