Name *

First Name

Last Name

Mobile Number *

(###)

###

####

Home | Office Phone Number *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Does your occupation require extended periods of sitting? *

Yes

No

Does your occupation require extended periods of repetitive movements? *

Yes

No

Does your occupation require you to wear shoes with a heel (dress shoes)? *

Yes

No

Does your occupation cause you anxiety (mental stress)? *

Yes

No

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you perform physical activity? *

Yes

No

In the past month, have you had chest pain when you were not performing any physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes

No

Stay connected with Oliveyah Fitness *

I would like to receive Mobile | Text updates from Oliveyah

Yes

No

Terms and Conditions *

1. I have been informed of the possible injuries and potential risk to life that may result from engaging in classes. I have indicated to Oliveyah Fitness that I am is in good health, physically able to undertake the rigors of this program and have no existing medical conditions or illnesses. 2. I, on behalf of myself, my heirs, executors, administrators, assigns, and successors hereby release and hold harmless Oliveyah Fitness, coaches, employees, and if applicable, leasers of the premises, with respect to any and all injury, disability, death, or loss of damage to person or property whether caused by the negligence of the releasees or otherwise from any act or acts, whether known or unknown, foreseen or unforeseen, as a result of participation in classes by Oliveyah Fitness. 3. I furthermore agree that Section 1542 of the California Civil Code shall have no effect. I hereby waive all rights under that Civil Code Section, California Civil Code Section 1542 states as follows: 1542 (Certain claims not affected by general release.) "A general release does extend to claims which the creditor does not know or suspect to exist in his/her favor at the time of executing the release, which if known by him/her must have materially affected his/her settlement with debtor." By clicking the "I agree to all Terms and Conditions" button, you, or acting as a guardian (if under the age of 18 years old), confirm that you understand each and every clause of this Agreement. And you furthermore confirm that this Agreement was freely and voluntarily executed and that no inducements, promises, representations, or other statements were made by anyone upon which you relied in agreeing to these terms and conditions of this Agreement.

I agree to all Terms and Conditions