Backyard Fitness Challenge

To register for an upcoming “Backyard Fitness Challenge” please follow the simple instructions below.

If paying by credit card:

1.      Go to www.perfitlife.com and click on Backyard Fitness Challenge.

2.      Complete registration form, agreement, medical history and release form and email to fitness@perfitlife.com.

3.      When we receive the completed forms and payment, we will contact you via phone or email with your registration number, which will be your Warrior number during training.

If paying by check or money order:

1.      Print the registration form, agreement, medical history and release form.

2.      Complete all forms – please print clearly.  Make checks payable to Perfit Life BFC.

3.      Mail the completed forms and payment to:

Perfit Life BFC

PO Box 40233

      Phoenix, Az. 85067

4.      When we receive the completed forms and payment, we will contact you via phone or email with your registration number, which will be your Warrior number during training.

Backyard Fitness Challenge Registration Form

Name: _____________________________________________________________

Street: _____________________________________________________________

City: ______________________ State: ___________ Zip Code: ________

Profession: __________________________________________________________

Date of birth: _____________________________

Home Phone: __________ Work Phone:_________Fax#:_____________

Email: __________________________________________________________

Emergency contact name: _____________________ Phone #: __________

Please confirm your challenge :

• Summer              July 6, 2009              Men ______

Payment method (check one):

• Credit card _______
• Check/Money Order ________

Backyard Fitness Challenge Agreement

1. I agree to show up for training every day unless it is an excused absence from my doctor or preapproved with Warrior Instructor.
2. I understand there is no refund policy.
3. I understand that photos or video may be taken during the course of my involvement in “Backyard fitness challenge” which may be used for promotional purposes.  I also understand that photos will not be used for any promotional purposes without my express written consent.
4. I understand that diet and nutrition will affect my fitness goals and performance during the “Backyard fitness challenge”.
5. I will remember to set my alarm and be ON TIME!

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Signature

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Printed name

_________________________________________

Date

Perfit Life Backyard Fitness Challenge Release Form

This release is entered into between the Undersigned and Perfit Life Backyard Challenge: Perfit Life, LLC, Perfit Life Personal Training, its members and managers.

The purpose of the “Backyard Fitness Challenge” is to provide fitness training and coaching for various levels of athletes/individuals.

Note: We reserve the right to refuse participation in the “BFC”, if the instructor feels that the safety of the group or individual would be in jeopardy.

The Undersigned hereby acknowledges that the following was explained to me and/or agree to the following:

1.      Acknowledges that Al Seif Hameed is not a physician and is not trained in any way to provide medical diagnosis or any other type of medical advice.

2.      Acknowledges that Perfit Life Backyard Fitness Challenge support staff, and affiliates are not physicians and are not trained in any way to provide medical diagnosis or any other type of medical advice.

3.      Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but Perfit Life Backyard Fitness Challenge, does not guarantee neither good nor bad will occur, nor guarantees the training advice given by Perfit Life Backyard Fitness Challenge will produce good or bad results.

4.      Acknowledges that the Undersigned has been told if they feel tired, feel pain, or feel out of the ordinary in any way, either related to your training or otherwise, that the Undersigned should contact a physician at once.

5.      Acknowledges that Perfit Life Backyard Fitness Challenge, aerobics, martial arts, kick-boxing, running, weight training, obstacle courses, and any other related sports/activities are an extreme test of one’s mental and physical limits and carry with it potential for damage or loss of property, serious injury and death.  That the Undersigned assumes the risks for participating in these types of events/activities, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that  they might develop.  The Undersigned expressly waive, release, discharge, and agree not to sue from any liability of death, disability, personal injury, or action of any kind Perfit Life Backyard Fitness Challenge, Al Seif Hameed for the Undersigned participating in said activities or events and/or training for said activities or events.

The Undersigned agrees that this is the full agreement between the parties, that Al Seif Hameed nor anyone else has not verbally contradicted any of the terms of the release and that the Undersigned has entered into this agreement free and voluntarily without force or coercion.

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Signature

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Printed Name

_________________________________________

Date

Medical History

 1.      Are you allergic to any medication (aspirin, penicillin, sulfa,etc.)? 

       Yes __ No__  If yes, please list:_________________________

2.      Do you take any prescribed medication on a regular basis?       

      Yes __ No__ If yes, please list:__________________________

3.      Do you have a seizure disorder (epilepsy)?   Yes __ No __           

4.      Do you have diabetes (adult or juvenile)?     Yes __ No __ 

5.      Are you anemic? Yes __ No __

6.      Do you have high blood pressure? Yes __ No __

7.      Do you have any of the following diseases?

      Heart Disease:    Yes __ No __            Lung Disease: Yes __ No __

      Kidney Disease: Yes __ No __            Liver Disease: Yes __ No __ 

8.      Do you have asthma? Yes __ No __

9.      Have you ever been knocked unconscious? Yes __ No __

10.  Have you ever had severe neck injury? Yes __ No __

11.  Do you wear glasses or contact lenses? Yes __ No __

12.  Have you had a broken bone or fracture in the past 2 years?

      Yes __ No __      If yes, please describe:_______________________

       ______________________________________________________

13.  Have you ever injured your back?

      Yes __ No __  If yes, please describe: _______________________

         _____________________________________________________

14.  Do you currently have back pain?  Never __Seldom __Occasionally __

       Frequently with vigorous exercise or lifting ___

15.  Have you had knee pain in the past two years that has disabled you for

      longer than a week? Yes __ No __ If yes, please describe: __________

      _______________________________________________________

16.  Do you have any other physical conditions which cause pain?

      Yes __ No __    If yes, please describe: ________________________

      _______________________________________________________

17.  Please describe  any surgeries you’ve had: _______________________

      _______________________________________________________

18.  On a scale from 1 – 10, rate your current fitness level (10 being the highest

       fitness level): ____________________________________________

19.  Are you training for a specific event:

      Yes __ No__  If yes, please describe: _________________________

      ______________________________________________________

PLEASE NOTE: It is wise to seek your doctors’ advice before beginning any health/fitness program!

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Signature

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