AISHA PT CLIENT APPLICATION – 10th Reach – Broadcast

Salutation *

First Name *

Last Name *

Date *

Height *

In inches.

Weight *

In lbs.

Age *

Personal Trainer's Name *

Email *

Phone Number *

Next Of Kin Name *

Next Of Kin Phone Number *

PAR-Q

Physical Activity Readiness Questionnaire.

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

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

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

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

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

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

Do you know of any other reason why you should not engage in physical activity? *

QUESTIONNAIRE

General & Medical Questionnaire.

Occupational Questions.

What is your current occupation? *

Does your occupation require extended periods of sitting? *

Does your occupation require extended periods of repetitive movements? (If yes, please explain on the next field.) *

If You Answered Yes To The Previous Question Please Explain Here

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

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

Recreational Questions.

Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain on the next field.) *

If You Answered Yes To The Previous Question Please Explain Here

Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain on the next field.) *

If You Answered Yes To The Previous Question Please Explain Here

Medical Questions.

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain on the next field.) *

If You Answered Yes To The Previous Question Please Explain Here

Have you ever had any surgeries? (If yes, please explain on the next field.) *

If You Answered Yes To The Previous Question Please Explain Here

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain on the next field.) *

If You Answered Yes To The Previous Question Please Explain Here

Are you currently taking any medication? (If yes, please explain on the next field.) *

If You Answered Yes To The Previous Question Please Explain Here

BEFORE & AFTER

Before And After Image

To support your personal trainer's brand and portfolio please feel free to upload an image of before your exercise which you agree will be used in marketing, please wear shorts and a bra and take an image standing sidewards, if you would like a professional image please notify your personal trainer. A before, and after images will be taken for your short term goal, mid term goal and long term goal equating to 3 images. If you do not want to upload an image please ignore this field.

Image Upload *

AGREEMENT

Newsletter *

Yes send me the newsletter double opt-in to my email

You will be sent a double opt-in for John Imani's Personal Trainer newsletter. After completing this application, please login to your email to confirm if you would like to be informed about new products/ services, promotions and sweepstakes. If you can not find the double opt-in confirmation in your inbox please check your junk mail otherwise feel free to contact us for support.

Privacy And Terms of agreement *

I agree

By choosing "I agree" and submitting your application form you agree to John Imani and 10TH REACH that the information provided is true and any false information is in violation of your application on behalf of your son/ daughter/ dependent, if approved for process of a contractual agreement. You also understand and agree our privacy policy regarding John Imani & 10TH REACH's handling of data, you understand and agree that you or/ and your son/ daughter/ dependent are a copyright owner or authorised to act on behalf of the owner of an exclusive right and you understand and agree to our copyright policy, you agree that you are 18 years old of age and above or a parent(s), competent adult/ age of majority consenting on behalf of a minor & understand the contract that will be provided for you to sign and also give permission for John Imani to market content to you once you have confirmed opting in via your email. To cancel the application form simply refresh this page/ navigate to another page or close the tab/ browser.

What Happen's Next

Once you have agreed and submitted your application form, you will be forwarded to to download your personal training programme.

Confirm *

Yes, I want John Imani and 10th Reach to keep my data and I want to be contacted by John Imani via 10th Reach.

Your agreement contracts and services/ products handling will be with Mr. John Imani and not the media company 10th Reach Global Ltd, however, this application is provided via 10th Reach Global Ltd and adheres to their policies, read more about how we use your information here.