Client Intake

Name*
First Last
Date*
MM slash DD slash YYYY
Age*
Date of Birth*
MM slash DD slash YYYY
Email*
Occupation*
Current Weight*
Ideal Weight*
Height*
Facebook Name*
Instagram Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone Number*
Marital Status*
Do you have children?*
- Yes
- No
How many?
Do you have supportive loved one’s and friends?*
- Yes
- No
Will they support you on your health & fitness journey?
- Yes
- No
Have you participated in an online program before?*
- Yes
- No
How was the experience?
What are your expectations of our program, and what do you hope to achieve?*
My health & fitness goals are:*
Do you smoke?*
- Yes
- No
How much?
Do you drink?*
- Yes
- No
How much?
Do you stress?*
- Yes
- No
Please explain:
Please list any medication’s that you are on:*
Do you have any prior surgery’s or health issues that may impede your success in this program?*

Are there any foods you will not eat?*
- Yes
- No
Please List:
Are you healthy and medically cleared to participate in an exercise/fitness program?*
- Yes
- No
What are your hobbies?*
Foods
Please list any foods that may have a less than favorable interaction with you that you have noticed in the past. Please list and explain how they may have affected you. If there's no issues please mark N/A.
Proteins*
Carbohydrates*
Fats*
Vegetables*
Please list all supplements that you take:*
What specific areas would you like to target for improvement:*
What external factors have derailed you in the past from being successful with a health & fitness program?*
In your opinion, why did you fail to “stick with it” in the past?*

Who will be supporting your efforts to achieve your goals?*
On a scale of 1 – 10, how serious are you about achieving your goals?*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Are there any conditions that we should be aware of that we may not have covered in the above listed paperwork? Please be very specific.*
What kind of cardio vascular exercise do you prefer to do? Please check top 2 that apply to you.*
- Treadmill
- Elliptical
- Seated bike
- Stair master
- Hiking
- Outdoor bike riding
- Other
What other(s)?
Do you currently do cardiovascular exercise?*
- Yes
- No
How many minutes per day?
How many days per week?
How many days per week can you commit to cardiovascular exercise?*
- 3
- 4
- 5
- 6
Do you currently do strength training / weights?*
- Yes
- No
How many minutes per day?
How many days per week?
How many days per week can you commit to strength training?*
- 3
- 4
- 5
- 6
What time do you prefer to do cardiovascular exercise?*
- AM
- PM
What time do you prefer to weight train or exercise?*
- AM
- PM
What days are ideal for you to train?*
Day Time
When were you in the best shape of your life?*
How old were you?*
What were you doing at that time?*
What gym or fitness center do you currently attend?*

Online Program Disclaimer for (LFF) Life Fuzion Fitness LLC
The health, fitness and nutritional information we offer is designed for educational and resource purposes only. This information is not a substitute for, nor a replacement of, professional medical advice, diagnosis, or treatment. If you have any concerns or questions about your health, you should consult with a physician or other health care professional prior to starting this program.

Please consult your physician or any other health care professional before starting this or any other fitness or nutrition programs to determine if they are right for your needs. Do not start a fitness and/ or nutrition program if your physician or health care provider advises against it.

Do not disregard, avoid or delay obtaining medical or health related advice from your health-care professional as a result of information you have obtained from our program. We are not certified or licensed nutritionists nor are we registered dieticians. The nutrition recommendations given in my program should serve as an outline for what we believe is appropriate for you based on the information you have provided to us.

The results, if any, from exercise and/or nutrition programs may vary from person-to -person. Further, engaging in any exercise, fitness or nutrition program involves risks of injury. If you choose to follow any of my fitness programs or nutrition recommendations, you acknowledge this and agree not to hold Kelly Schmidt, Christine Schmidt, and LFF Life Fuzion Fitness responsible for any injuries or damages you may incur. I disclaim all liability for loss, injury or damages in conjunction with any content provided in our programs. The use of any information provided from us or any of our programs is solely at your own risk.
Accept Disclaimer*
- Check this box if you acknowledge that you read and fully understand the contents of this disclaimer

Terms of Agreement for (LFF) Life Fuzion Fitness LLC
RELEASE OF LIABILITY (PLEASE READ CAREFULLY):

I have enrolled in a program of strenuous physical activity including, but not limited to walking, running, boxing, yoga, aqua aerobics, aerobics, massage therapy, weight lifting, bicycling, in line skating, skating, and the use of various conditioning and exercise equipment and facilities designed, offered, recommended, and/or supervised or unsupervised by Kelly Schmidt, Tina Schmidt & (LFF) Life Fuzion Fitness LLC. I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit my participation in this program. In consideration of my participation in this program, I for myself, my employees, heirs, assigns, agents, officers, directors, shareholders and coworkers hereby release Kelly Schmidt, Tina Schmidt, (LFF) Life Fuzion Fitness LLC. Employees, heirs, assigns, agents, officers, directors, and shareholders, from any and all claims, demands or causes of action arising from my participation in the program. I fully understand that I may suffer injury as a result from my participation in the program and I hereby release Kelly Schmidt, Tina Schmidt & (LFF) Life Fuzion Fitness LLC. From any and all liability now or in the future, including but not limited to medical expenses, lost wages, pain and suffering, that may occur by reasons of heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries, and any other illness, soreness, injury, however caused, whether occurring during or after my participation in the program, regardless of fault. I attest, contract, acknowledge, and agree that I am legally bound by its content.

I hereby agree and accept to be legally bound by this agreement. By signing this document, I attest, contract, acknowledge, and agree that I am legally bound by its content.
Accept Agreement*
- Check this box if you agree and understand the terms of agreement

Refund Policy for LFF
I, (the client) understand that under no circumstances or reasons am I due a refund or return, partial or full from Life Fuzion Fitness LLC. If I choose to quit or discontinue the LFF program I do not expect nor will I receive a refund. I also understand I have joined either a 30-day program 12-week (3) month, or 24-week (6) month on line nutrition & fitness coaching program. I will be billed either (1x) on a paid in full agreement on the card I provided for my program or the 12-week (3) month program or the 24-week (6) month program. If I opt to do the monthly payment plan for any program I choose, I will pay my first payment immediately, then every (30) days from my first payment date additional payments will be automatically made to satisfy my contractual time commitment. If I choose to discontinue or abandon the program I will still be responsible for any remaining payments left as agreed upon in my 12-week (3) month or 24 week (6) month program commitment to Life Fuzion Fitness LLC. If you are on the month to month on going Foundations Program you understand that a 30 day cancellation is required to cancel the ongoing subscription/membership to the Foundations Program. In order to cancel your Life Fuzion Fitness Foundations Program. Please send 30 day cancel request to info@lifefuzionfitness.com.
Accept Refund Policy*
- Check this box if you agree to these terms

New Client Liability/Waiver Agreement
BY SIGNING, YOU ARE AGREEING TO ACKNOWLEDGEMENT OF ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF LIFE FUZION FITNESS LLC. Signee acknowledges that LIFE FUZION FITNESS & All programs provided by LFF hereunder includes participation in strenuous physical activities, including but not limited to, weight training and various aerobic exercises. Signee will be referenced to as “Client” for the remainder of this paragraph. Client acknowledges these Physical Activities involve inherent risk of physical injuries or other damages, including, but not limited to, heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries and other illness, soreness, or injury however caused, occurring during or after the Clients participation in the Physical Activities. Client further acknowledges that such risks include but are not limited to, injuries caused by the negligence of an instructor or other person, defective or improperly used equipment, over exertion of a Client, slip and fall by Client, or an unknown health problem of Client. Client agrees to assume all risk and responsibility involved with participation in the Physical Activities and or following an exercise program, nutrition suggestion, meal plan suggestion, or supplement suggestion by LIFE FUZION FITNESS. Client affirms that Client is in good physical condition and does not suffer from any disability that would prevent or limit participation in the Physical Activities. Client acknowledges that participation will be physically and mentally challenging, and Client agrees that it is the responsibility of Client to seek competent medical or other professional advice regarding any concerns involved with the ability of Client to take part in the Physical Activities. By signing this Agreement, Client asserts that he or she is capable of participating in the physical activities. Client agrees to assume all risk and responsibility for exceeding his or her own physical limits. Client, agrees to fully release Kelly Schmidt, Tina Schmidt & LIFE FUZION FITNESS (as well as any of its owners, related entities, employees or other authorized agents, including Independent Contractors) from any and all liability, claims and/or litigation actions that Client may have for injuries, disability or death or other damages of any kind, including but not limited to punitive damages, arising out of participation in the Physical Activities, exercise program, or nutrition program.
Consent*
I agree to the new client liability/waiver agreement.

Program Expectations
I understand that this is a self-directed online program, and my success fully relies on me following the program and completing the tasks provided to me?*
- Yes
- No
Changes or alterations to your meal plans and/or macros are typically done every 3-5 weeks or longer depending on the results you are having. If your nutrition plan is working and we are continuously seeing results week to week on your check ins we may not alter your plan until necessary. If you have a standard meal plan, (meaning we basically tell you what to eat with small variables of change) You understand we do not provide new menus daily and/or weekly. The standard plan you have is what we will follow. The human body takes a minimum of 21-28 days to respond to stimulus provided via nutrition. So that is why we like to keep it simplified in the pursuit of your goals. If you are on a macros-based plan you have the flexibility to create your own meal plans based on the macros that we provide you. Do you understand this?*
- Yes
- No
CHECKINS ARE ON FRIDAY MORNINGS! They are due by 12pm MST at latest. If that day or time does not work, please communicate that with us ASAP! If you do not get your check-ins in by the specified time and you do not communicate with us, you will have to wait for the following week for adjustments. Please do the check-ins as specified via instructions/video housed in membership site. You will also at minimum need to log your Friday AM weight as well. You may load measurements as well, however that is up to you. I will load a check in sheet every Thursday night in the app’s chat/messaging feature that you will need to fill out for your Friday morning check-ins. Do you understand and agree with this?*
- Yes
- No
I agree to review all of the materials provided to me in my membership site before asking questions pertaining to my program.*
- Yes
- No

Step 1 of 9

Foods

Online Program Disclaimer for (LFF) Life Fuzion Fitness LLC

Terms of Agreement for (LFF) Life Fuzion Fitness LLC

Refund Policy for LFF

New Client Liability/Waiver Agreement

Program Expectations

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