Date:

Time:

Name:

Age:

Address:

Phone (H):

Please circle your answer to the following questions:

1) Have you joined a fitness club before?

YES/NO

If YES, is your membership current?

YES/NO

2) Are you currently exercising?

YES/NO

3) What results do you want to achieve from coming to the gym?

Fitness

Weight Loss

Tone

Strength

Build

4) Which of the following activities are you interested in?

Classes

Yoga

Free Weights

Cardio

Pilates

5) How many days per week would you like to exercise?

6) What has kept you from starting an exercise program?

7) What length of program would suit you?

Casual

3mth

6mth

12mth

Monthly

8) How did you hear about Pumphouse Fitness Club?

Newspaper

Internet

Yellow Pages

Promotion

Waked By

Friend

9) Have you any injuries, illnesses or limitations (heart problems, high blood pressure etc) that would prevent you exercising?      YES/NO

If YES, please explain

Upon signing this form I do hereby agree to the following:

a) To abide by the Rules and Regulations of Pumphouse Fitness Club and take responsibility for any damage caused by me to the facilities and equipment of Pumphouse Fitness Club.

b) That Pumphouse Fitness Club shall not be held responsible for personal injury sustained by me in, on or about the facilities, without limitation, any claim for personal injuries resulting from or arising out of negligence by Pumphouse Fitness Club or their directors, officers or employees, or the negligence of any other person using the facilities.

Signature: