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Registration Form

BODY BY JEANAI LLC Registration Form

If you are making a payment for a Fitness Evaluation, you will receive a call within 24 hours to set appointment date and time.

Personal Information

Self Assessment and Additional Information

I rate my current fitness level as (1 - 10) ten being the highest

How did you hear about us?

please specify website, publication or name of friend

This is my first Body By Jeanai Boot Camp, Core Stability Training, Li-Hi Body Blast, Mega Meltdown and/or Zumba:

If you answered "no" to the above question, when was the last phase you attended?

Name of Emergency Contact & Phone Number

Program and Payment Information

Choose the group fitness program you are registering for:

Choose the type of training you are making payment for:

Choose the service you are registering for:

Choose the "special" or gift certificate you are paying for:

Choose your form of payment

Whether you are a new, actively training client or returning group fitness participant

all fields are required to be filled out.

2. Do you take any prescribed medication on a permanent or semi-permanent basis?

3. Do you have a seizure disorder (epilepsy)?

4. Do you have diabetes Adult or Juvenile?

List Type and medications:

5. Are you anemic (low blood count)?

6. Do you have High Blood Pressure (hypertension)?

7. Do you have or have you ever had the following diseases:

8. Do you have asthma?

9. Have you ever had a severe neck injury?

Describe

10. Have you ever been knocked out?

Describe:

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

Describe:

12. Have you ever injured your back?

Describe:

13. Do you have back pain?

14. Have you had knee pain in the past 2 years that has disabled you for longer than a week?

Describe:

15. Do you have other physical conditions which cause pain?

Describe:

16. Detail any surgical procedures:

17. What are your goals for the next three months?

18. Are you training or needing to get in shape for a specific event?

If yes, explain:

19. What was your weight 2 years ago?

20. Have you recently had your body fat tested?

If "yes" what is the percentage?

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

NOTICE: It is wise to seek your doctor(s) advice before beginning any health/fitness/nutrition program!

This release is entered into between the undersigned and Body By Jeanai LLC., its officers, subsidiaries, affiliates, executors and heirs in addition to the City of Chicago Park District, Chicago Public Schools, Charter Schools and/or the Jacobs Well Facility. The purpose of Body By Jeanai Fitness Programs including Boot Camp / Core Stability /Li-Hi Body Blast /Meg Meltdown /Zumba Fitness /Personal Training/ Couples Training/ Trio Training/ Virtual Training is to provide fitness instruction and coaching for various fitness levels of individuals/fitness enthusiasts/athletes.

The undersigned hereby acknowledge that the following was communicated on the website, I have read it and I agree to the following:

Acknowledges that coaching/training is another tool for teaching individuals/fitness enthusiasts/athletes about themselves and muscular response, but that Body By Jeanai LLC does not guarantee that fitness advice or exercises given by Jeanai Chassagne will cure, correct any illness or medical condition nor guarantee to produce results to meet or exceed an individuals fitness goal for results vary upon individuals diet, effort and activity levels.

Acknowledges that individual and semi-private fitness training, boot camps and the other group fitness program offered by Body By Jeanai, are an extreme test of one's mental and physical limits. The undersigned assumes the risks of participating in these types of events/activities including the elements of a natural environment, 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 Body By Jeanai LLC or Jeanai Chassagne for the undersigned participating in said fitness programs neither group training, individual, semi-private or virtual training.

Acknowledges that after registering for a group fitness program but becomes unable to attend due to circumstances out of your control and Body By Jeanai is notified 72 hours prior to your registered sessions start date, we can offer you a credit toward a future phase of that group fitness program. This credit will have to be used within a 3 month time frame from your originally registered program. This credit is non-transferable and there is no cash refund. This is policy is non-negotiable.

The Undersigned agrees that this is the full agreement between the parties, that Body By Jeanai LLC including neither Jeanai Chassagne nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion.

Agreement and Signature

I have read and agree to all terms and conditions

above.

Electronic Signature