Start Your Journey Here

GENESIS WELCOME PACKAGE

Welcome Pack

Hi there!

Attached you will find a few forms that will help you get started on your health and wellness journey here at Genesis.

Fill these out at your earliest convenience- these forms take 15 minutes to review and 30 minutes to complete. Please reach out if you have any questions!

Liability Form

Section 1

Your Information

First Name

Last Name

Date of Birth

Phone number

Section 2

Emergency Contact Information

First Name

Last Name

Relationship

Phone number

This contact will only be used in case of emergency during training sessions.

Section 3

Health & Medical Acknowledgment

I certify that I am physically able to participate in an exercise program. I understand it is my responsibility to consult with a physician prior to participation.

I agree to disclose any injuries, illnesses, or medical conditions that may affect my ability to exercise safely.

Section 4

Assumption of Risk

I understand that participation in physical exercise involves inherent risks, including but not limited to:

Muscle strains
Injury
Illness
Serious injury or death
I voluntarily assume all risks associated with participation.

Section 5

Release of Liability

I hereby release, waive, and discharge the trainer from any and all liability, claims, demands, or causes of action arising out of or related to any injury, damage, or loss that may occur as a result of participating in training programs, whether caused by negligence or otherwise.
I agree that I participate at my own risk.

Section 6A

Online Training Disclaimer

I understand that:

Training is conducted remotely
The trainer cannot physically assess my form or environment
I am responsible for performing exercises safely

I understand that online coaching limits the trainer’s ability to physically assess posture, technique, and environment.
I accept full responsibility for ensuring that I perform exercises safely and within my limits.

Section 6B

No Guarantee of Results

I understand that results vary and are not guaranteed. Progress depends on my effort, consistency, and lifestyle.

Section 7

Code of Conduct / Zero Tolerance Policy

I agree to maintain respectful and professional communication at all times.
Zero tolerance for harassment, abuse, racism, sexism, or any discriminatory behavior.

Violations may result in immediate termination without refund.

Trainer reserves the right to terminate services if behavior is inappropriate or undermines coaching progress.

Section 8

Scheduling & Missed Sessions

I understand that a minimum of 24 hours’ notice is required to reschedule check-ins. Missed sessions without proper notice are forfeited and cannot be rescheduled.

Section 9

Payment & No Refund Policy

All monthly payments are due the 5th day of every month through scheduled payments and/or auto payments with card on file and are non-refundable. Timely payment ensures scheduled service continues through the end of the month.

If I choose to discontinue services before the end of the billing period, I forfeit the remaining time and payment for that month.

Section 10

Governing Law & Jurisdiction

This Agreement is governed by the laws of the Commonwealth of Pennsylvania, without regard to conflict of law principles.

Any legal action shall be brought exclusively in the state or federal courts located in Pennsylvania.

Section 11

Severability

If any provision is found invalid, the remaining provisions shall remain in full effect.

Section 12

Consent & Agreement

I have read, understood, and agree to all terms outlined in this waiver.
I acknowledge that this document is legally binding.

I agree to the terms:

Yes

First Name

Last Name

Date / Time

PAR-Q Health Screening

The Physical Activity Readiness Questionnaire for Everyone

Has a doctor ever said that you have a heart condition OR high blood pressure?

Yes

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Yes

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?

Yes

Have you ever been diagnosed with another chronic medical condition (other than high blood pressure or heart condition)?

Yes

If so, list here.

Are you currently taking prescribed medications for chronic medical condition(s)?

Yes

If so, list here.

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

Yes

If so, list here.

Has your doctor ever said that you should only do medically supervised physical activity? If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION

Yes

Participation Declaration

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the Genesis Fitness may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

I agree to the terms:

Yes

First Name

Last Name

Date / Time

If you answered YES to one or more of the questions above, COMPLETE PART 2:

PAR-Q Health Screening

PART 2

Do you have Arthritis, Osteoporosis, or Back Problems?

Yes

If so, list here.

Do you currently have Cancer of any kind?

Yes

If so, list here.

Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm

Yes

If so, list here.

Do you currently have High Blood Pressure?

Yes

If so, do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes?

Yes

If so, do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

If so, do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician- prescribed therapies?

Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome?

Yes

Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia

Yes

Have you had a Stroke?

Yes

Do you have any other medical condition not listed above or do you have two or more medical conditions?

Yes

If so, list please.

Participation Declaration

I agree to the terms:

Yes

First Name

Last Name

Date / Time

INTAKE FORM

This form will help us determine where to start on your fitness journey and any relevant information that can be useful during our time together!

Age

Height

Weight

Job Occupation

How many days AND hours are you at work?

Morning person or Night owl?

What time do you usually go to sleep and wake up?

How many meals & snacks do you have a day?

What time of the day do you have the least amount of energy?

When do you have the most energy during the day?

What is your mode of transportation? (car, bike, bus)

Are there any aches or pains in your body that you want to address? (pain when bending or walking, joint pain, pain in the morning)

What physical activity do you enjoy doing? (walking, soccer, baseball, running, etc.)

What can’t you do now that you want to be able to do fitness and health wise?

What is your overall fitness goal? (lose weight, eat better, get strong, etc,)

Do you currently have access to a gym? Do you prefer home work outs or gym?

Do you acknowledge that your health is your responsibility?

Yes

Do you acknowledge it is your responsibility to follow and complete your fitness plan, along with any changes and improvements in accordance with what you and your trainer agree to?

Yes

Maybe

Do you acknowledge you will only see results if you, yourself, agree to follow and continuously improve on your personalized fitness plan?

Yes

Maybe

Do you have a strong support system for your fitness journey?

Yes

Do you acknowledge that your personal trainer can void your contract if there is a lack of consistent participation and willingness to participate and engage in this program?

Yes

Numeric Field

You have completed the intake questionnaire.