Name Company/Sport
 
Address Email
 
City Zip
 
Phone No Mobile
 
Age Male/Female
 
Marital Status : Single / Married Do you have any children? Yes/No
 
Have you been here before?Yes/No Are you currently involved in an excercise program? Yes/No
 
WHAT ARE YOUR FITNESS GOALS? CHECK ALL THAT APPLY HOW DID YOU HEAR ABOUT GOLD'S GYM?
Lose Weight - How Much Referred by
Gain Weight - How Much Television
Cardiovascular conditioning Radio
Tone and Firm Newspaper
Increase muscular strenght/size Direct Mail
Stress management Drive by
Injury rehabilitation Other
Other
 
HOW LONG HAVE YOU BEEN THINKING ABOUT ACHIEVING YOUR GOALS? 1MTH 3MTHS 6MTHS ONE YEAR OR MORE
 
ON A SCALE OF 1-10 (10 BEING MOST SERIOUS) HOW SERIOUS ARE YOU ABOUT ACCOMPLISHING YOUR GOALS? 12345678910
WAIVER
I accept responsibility for my use of any and all apparatus, appliances, facility, priviledge or service whatsoever, owned and operated at this club at my own risk, and shall hold this club, its shareholders, directors, officers, employers representatives and agents harmless from any and all loss, claim, injury, damage, or liability sustained or incurred by me resulting therefrom.
Signature