Challenge Registration

Come Back Challenge Registration

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Are you currently participating in any other nutrition support program? *

- NO - YES

If yes, what program? Example: Weight Watchers, Portion Fix, Jenny Craig, etc *

Please answer the following questions. You are not asked to provide the trainer with the answers to these questions for registration. However, to ensure your safety, please review these questions.

Has a doctor ever said you have heart trouble or a heart condition?
Do you frequently suffer from pains in your chest?
Do you have high blood pressure?
Do you have high cholesterol?
Do you often feel faint or have spells of severe dizziness?
Do you have a bone or joint problem that can be made worse by exercise?
Do you have Diabetes — insulin controlled or uncontrolled?
Are you taking any medications such as Beta-Blockers, diet pills, or herbal supplements?
Are you pregnant?
Do you have asthma?

IMPORTANT: If you answered “yes” to 2 or more of the above questions, you may be at risk during a rigorous exercise program. It is always recommend to have approval by your doctor to participate in a vigorous exercise program if you have 2 or more of the above conditions. By completing your registration, you agree you have answered this health history form truthfully and understand it is in your best interest to obtain a your physician’s release if you are at increased risk.

Do you have a smart phone to access Apps? *

YES NO

Do you have a Facebook Account? *

Yes, It is an active account. Yes, but I rarely use it. No, not at the moment.

The following information is needed for the coach to calculate your daily calorie needs.

Age *

Height in Inches *

Body Weight in Lbs *

Waiver and Release of Liability
Please read and sign.
I declare that I voluntarily wish to participate in the fitness/ wellness challenge with Coach Dana Sandmeyer.

I have been advised by the coach of the importance and/or need of a physical exam and also of the risk of injury when participating in an exercise program.

I hereby REPRESENT and WARRANT that I am physically capable of participating in the program and that I am not aware of any physical illness or condition that could increase my risk of injury during such participation.
I understand there are risks of injury associated with participation, I am aware of the risks inherent in any exercise/health program, including but not limited to severe personal injury and death. I understand that through my participation, I am subject to possible injury, and also understand that by my participation, I accept the risk of possible injury.
I, on behalf of my heirs, personal representative agents or assigns, hereby WAIVE AND RELEASE Dana Sandmeyer from any and all claims, costs, liabilities, expenses or judgments, arising out of my participation. I also agree to indemnify and hold harmless Dana Sandmeyer and those affiliated with such, from and against any and all such Claims.
By signing I declare that I have read and understand the above WAIVER AND RELEASE.

Once your registration is received by your coach, you will be sent an email that will include additional information that is needed to finalize your registration. The information will include a Nutrition History Questionnaire and a Current Physical Fitness Questionnaire.

SIGNATURE *

Comment/Questions? *

Submit