New Member Assessment

Welcome to Rochester School of Fitness. This intake helps us build a program that’s safe and right for you. It takes about 10–15 minutes — take your time, and reach out if anything is unclear.

Your privacy: the information you share here is used only by RSF to plan your program safely. We never sell or share it. Fields marked * are required. Questions? Call us at 585-210-9542.

Personal Information

First Name * Last Name * Date of Birth * Gender Phone * Email *

Street Address

Occupation How did you hear about RSF?

Emergency Contact

Emergency Contact Name * Relationship

Emergency Phone *

Physician & Medical Clearance

Primary Care Physician Practice / Clinic Physician Phone

Cleared for exercise by physician?

Yes

Not required / unsure

Medical History Known medical conditions (check all that apply) Other conditions not listed Recent surgeries or injuries? (past 12 months) Current medications (name, dose, frequency, reason)

Current Activity Current Activity Level Types of Exercise Currently Doing

Cardio days/week Strength training days/week Average daily steps

Exercise limitations or restrictions Previous programs or trainers

Lifestyle & Nutrition

Eat breakfast daily? Water glasses/day Fruits & vegetables/day Meals eaten out/week Sleep hours/night Stress level (1–10) Dietary preference Alcohol consumption Tobacco use

Your Goals What are your goals? (check all that apply) Describe your #1 goal in your own words What has held you back in the past? Timeline

Adult Participation Waiver & Release of Liability

I, the undersigned, acknowledge that participation in physical fitness activities, exercise programs, and use of fitness equipment at Rochester School of Fitness (“RSF”), located at 445 W. Commercial St., Suite #4, East Rochester, NY 14445, involves inherent risks of physical injury, including but not limited to: muscle strains and sprains, joint injuries, cardiovascular events, falls, and in rare cases, death. I voluntarily assume all such risks, known and unknown.

In consideration of being permitted to participate in RSF programs and use RSF facilities, I hereby release, waive, discharge, and covenant not to sue Rochester School of Fitness, The Fitness Initiative, Inc., and their respective owners, directors, employees, agents, instructors, and representatives (collectively “RSF Parties”) from any and all claims, demands, damages, costs, or causes of action arising out of my participation, including claims arising from the negligence of RSF Parties, to the fullest extent permitted by the laws of the State of New York.

I agree to indemnify and hold harmless all RSF Parties from any loss, liability, damage, or cost they may incur arising from my participation in RSF programs, including reasonable attorney’s fees.

I confirm that I have disclosed all known medical conditions, medications, injuries, and limitations in this intake form. I understand that failure to disclose relevant health information may increase my risk of injury and releases RSF from liability related to undisclosed conditions.

I grant RSF permission to photograph or record me during participation for use in promotional materials, social media, and marketing, unless I indicate otherwise below by checking the opt-out box.

This agreement shall be governed by the laws of the State of New York. If any provision is found invalid or unenforceable, the remaining provisions shall remain in full force and effect. This waiver constitutes the entire agreement between the parties with respect to its subject matter.

I have read this waiver carefully, understand its terms fully, and sign it freely and voluntarily. I am 18 years of age or older and legally competent to enter into this agreement.

I have read and fully understand the Adult Participation Waiver and Release of Liability above. *

I voluntarily agree to all terms and conditions stated in this waiver. *

All information in this form is accurate and complete to the best of my knowledge. *

I agree to notify RSF of any changes to my health status, medications, or emergency contact.

❌ I DO NOT consent to photos or video of me being used in RSF marketing materials. (Leave unchecked if you consent.)

Full Legal Name (Electronic Signature) * Date *

By typing your name above, you are providing a legally binding electronic signature under the New York State Electronic Signatures and Records Act (ESRA). RSF recommends consulting a licensed New York attorney with any questions about this waiver before signing.

Registering a Minor? (ages 8–17) — optional

Only complete this section if you are a parent or legal guardian registering a minor. Minors between the ages of 8 and 17 may not participate without a signed parental consent and waiver on file; the minor cannot sign on their own behalf.

Minor’s Full Legal Name Minor’s Date of Birth Minor’s Age (8–17) Relationship to Minor Guardian Phone Guardian Email

Minor’s Primary Care Physician Minor’s known medical conditions, allergies, or limitations Minor’s current medications

I, the undersigned parent or legal guardian, hereby grant permission for the above-named minor to participate in fitness programs, classes, and activities offered by Rochester School of Fitness (“RSF”) and/or The Fitness Initiative, Inc. at 445 W. Commercial St., Suite #4, East Rochester, NY 14445, and at any off-site locations used by RSF for programming.

I acknowledge that participation in physical fitness activities involves inherent risks of injury for the minor participant, including but not limited to: muscle strains, joint injuries, falls, cardiovascular events, and in rare cases, death. I voluntarily assume all such risks on behalf of the minor and myself, and acknowledge that these risks exist despite all reasonable safety precautions taken by RSF staff.

On behalf of myself, the minor, and our heirs, executors, administrators, and assigns, I hereby release, waive, discharge, and covenant not to sue Rochester School of Fitness, The Fitness Initiative, Inc., and their respective owners, directors, employees, agents, and instructors (collectively “RSF Parties”) from any and all claims, demands, damages, costs, or causes of action arising out of the minor’s participation, including claims arising from the negligence of RSF Parties, to the fullest extent permitted under the laws of the State of New York.

I agree to indemnify, defend, and hold harmless all RSF Parties from any loss, liability, damage, claim, or cost they may incur arising from the minor’s participation in RSF programs, including reasonable attorney’s fees and court costs.

I confirm that I have disclosed all known medical conditions, allergies, medications, injuries, and physical limitations of the minor participant in this form. I agree to promptly notify RSF staff of any changes to the minor’s health status before or between sessions.

I acknowledge that while RSF staff will actively supervise the minor during all scheduled programming, RSF is not responsible for supervising the minor outside of scheduled program hours. I agree to ensure the minor is picked up promptly at the end of each session, and that the minor will comply with all RSF rules, staff instructions, and codes of conduct. RSF reserves the right to remove any minor from a program for behavioral or safety reasons, with notice to the parent or guardian.

I grant RSF permission to photograph or record the minor during participation for use in promotional materials, social media, and marketing, unless I indicate otherwise by checking the opt-out box below.

I have read this entire waiver carefully, understand its terms fully, and sign it freely and voluntarily as the parent or legal guardian of the above-named minor participant. I understand this is a legally binding agreement.

I have read and fully understand the Minor Participant Waiver and Parental Consent above.

I voluntarily consent to the minor’s participation and agree to all terms stated in this waiver.

❌ I DO NOT consent to photos or video of the minor being used in RSF marketing materials.

Parent / Guardian Full Legal Name (Electronic Signature) Date

A member of the RSF team will follow up to schedule your first session.