1. health and fitness

www.fitnesswithpj.com
Please fill out these forms and then email them, or mail, or drop off with your registration fees to:
5446 13B Ave, Tsawwassen V4M 3W7. Cash, eTransfer or cheque will be accepted (cheques
made payable to PJ Wren).
To eTransfer the monies for your class: please follow the instructions found on your online
banking and use the password “bootcamp”. Also note which class you are registering for in the
“comment” section of your eTransfer (all major banks process eTransfers, and they are very easy
to do!).
More info: pj@fitnesswithpj.com
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EARLY BIRD for JUST TRAIN (Registration before March 7 )
3x week: $370+ $18.50 (GST) = $388.50
2x week: $265 + $13.25 (GST) = $277.25
1x week: $140 + $7.00 (GST) = $147.00
REGULAR BIRD
2x week: $285 + $14.25 (GST) = $299.25
1x week: $160 + $8.00 (GST) = $168.00
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All classes are held at: United MMA #107 5405 12 Ave, Tsawwassen
The Not-So-Small-Small-Print (the Terms):
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Easter Monday, April 6 , class is cancelled and will be held after set is completed on Mon, May 4th
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Classes commence week of March 9 and end week of April 27 2015
Program runs for 8 weeks
Classes are 45-55 minutes in length
There are no refunds or class carry overs if you can’t get all in all your classes before this set is finished
Make-up classes can be booked based on an availability basis and must be booked before this set is completed
If you are away for the 2 weeks of Spring Break please let me know. I can pro-rate your program if you are
registered for 2-3 times a week and off from class for the whole 2 weeks of Spring break. If you are only away for
1 of the weeks I will have a make-up class at the end of the set (Monday, May 4th at 6pm and Wednesday, May
6th at 6pm), as well as the ability to make up any other missed classes through the 8-week set.
Participant Information:
Name:__________________________________________________________________
Age:_________________ Phone: ____________________________________________
Email address: ___________________________________________________________
(Please print clearly!)
Please circle Or Check which classes you are registering for:
Tues 8:00am
Thurs 8:00am
Fri 9:30am
Just Train!
Just Train!
Just Train!
Mon 6pm
Tues 9:15am
Wed 6pm
Thurs 9:15am
Just Train!
Just Train!
Just Train!
Just Train!
PAR-Q
DO YOU HAVE, OR HAVE YOU HAD, IN THE PAST:
1. History of heart problems, chest pain or stroke?
YES
NO
2. Increase or decreased blood pressure?
YES
NO
3. Any chronic condition or illness?
YES
NO
4. Encouraged by a doctor to begin an exercise program.
YES
NO
5. Recent surgery (last 12-months).
YES
NO
6. Pregnancy (now or within the last 3-months)
YES
NO
7. History of breathing problems.
YES
NO
8. Muscle, joint, back disorder or any other injury still affecting you.
YES
NO
9. Diabetes or thyroid condition.
YES
NO
10. Cigarette smoking habit.
YES
NO
11. Increased blood cholesterol.
YES
NO
12. History of heart problems in immediate family.
YES
NO
13. Hernia or any other condition that may be aggravated by lifting weights.
YES
NO
14. Are you taking any prescription medications?
YES
NO
PLEASE EXPLAIN ANY “YES-ES” TO THE ABOVE QUESTIONS, IN DETAIL.
_____________________________________________________________________________
_____________________________________________________________________________
PARTICIPANT RELEASE OF LIABILITY & KNOWLEDGE OF AGREEMENT
In consideration of being allowed to participate in the personal and/or group fitness training
activities and programs of Fitness with PJ, PJ Wren, United MMA and to use its facilities,
equipment and services, in addition to the payment of any fee or charge, I do hereby forever
waive, release and discharge Fitness with PJ, PJ Wren, United MMA and its trainers,
contractors, instructors, employees, representatives and all others acting on their behalf from any
claims or liabilities for injuries or damages to my person and/or property, including those caused
by the negligent act or omission of any of those mentioned or others acting on their behalf, arising
out of or connected with my participation in any activities, programs or services of Fitness with
PJ , PJ Wren, United MMA or the use of any equipment at various sites, including home,
provided by and/or recommended by Fitness with PJ, PJ Wren, United MMA.
(PLEASE INITIAL: ________ )
I understand and am aware that strength, flexibility and aerobic exercise, including the use of
equipment, are all potentially hazardous activities. I also understand and am aware that fitness
activities involve a risk of injury, including a remote risk of death or serious disability, and that I
am voluntarily participating in these activities and using equipment and machinery with full
knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly
assume and accept any and all risks of injury or death.
(PLEASE INITIAL: _________ )
I do hereby further declare myself to be physically sound and suffering from no condition,
impairment, disease, infirmity or other illness that would prevent my participation in these
activities or use of equipment or machinery. I do hereby acknowledge that I have filled out the
Health History truthfully and that I may need my physician’s clearance to begin my fitness
program with Fitness with PJ, PJ Wren. I acknowledge that either I have had a physical
examination and have been given my physician’s permission to participate or I have decided to
participate in the exercise activities, programs and use of equipment without the approval of my
physician and do hereby assume all responsibility for my participation in said activities, programs
and use of equipment.
(PLEASE INITIAL: _________ )
I understand that Fitness with PJ, PJ Wren is providing and maintaining a fitness program for
me and it does not constitute an acknowledgment, representation or indication of my
physiological well-being or a medical opinion relating thereto.
(PLEASE INITIAL: _________ )
I understand the results of any fitness program cannot be guaranteed and my progress depends
on my effort and cooperation in and outside of the sessions.
(PLEASE INITIAL: _________ )
I understand that classes are non-refundable, owed prior to the program commencing and that
there may be no make up classes if I should miss a class.
(PLEASE INITIAL: _________ )
I, ______________________________________ have read and understand the terms of the
exercise program. I also grant permission to have photographs and/or video of my person and/or
voice on still, or motion picture film and I waive any claim of remuneration of use of audio - visual
material and I understand that all material remains the property of PJ Wren.
(PLEASE INITIAL: _________ )
______________________________
SIGNATURE
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DATE