EMF Lifting & Laughing Child PT Inquiry Form

EMF Lifting & Laughing Child PT Inquiry Form
Name
Age
Date of Birth

Month Day Year
Email
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City County

Eir Code
Tell us a little more about you
What made you decide to fill out this form today?
Do you know much about EMF and our particular brand of Lifting & Laughing?
Has your child/ teen ever done PT in the past or have they any experience doing resistance training? If so please tell us how they felt about it and if there was anything they didn't like about their experience.
What are you hoping for your child/ teen to get out of training in EMF? Please feel free to go into as much detail as possible.
"Gym for shape, diet for weight" is one of our motto's in EMF. If weight loss is a goal of yours for your child/ teen we work with a fantastic nutritionist that we can refer you on to. If you are already following a diet plan for your weight loss goal that is totally fine too. Would you like to be refereed to out nutritionist?
We offer 4 x 30 minute sessions over 4 weeks. These sessions are private 1 to 1 sessions and include a mixture of strength, coordination, balance and skill focused exercises with an emphasis on fun. These sessions are €120 for the 4 weeks. We also do an induction process (cost €30), this is a once off payment as we don't know how the child/ teen will take instruction. Does all that sound good to you?

Yes No
Does your child/ teen have any previous injuries (sport or otherwise)? Do they have any medical issues which may effect their ability to perform any exercises? Please feel free to go into as much detail as possible.
How comfortable is your child/teen at taking instruction? How comfortable are they with being in a new environment? Do they get shy easily or do they struggle socially?
What is their favourite song to exercise to or just in general?
Acknowledgment, Authorization and Waiver
Due to the fact that physical exercise can be strenuous and subject to risk of serious injury, we urge you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You agree that by participating in physical exercise or training activities, you do so entirely at your own risk. You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury. We are also not responsible for any loss of your personal property. You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a release of liability. You expressly agree to release and discharge the trainer or instructor from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer or instructor for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence. By signing this release, I acknowledge that I understand its content and that this release cannot be modified orally.
Date Signed

Month Day Year
Patient/Parent/Guardian Signature

Clear
Should be Empty:

EMF Lifting & Laughing Child PT Inquiry Form

Tell us a little more about you

Acknowledgment, Authorization and Waiver