Application for Results Only membership Application for Acceptance for Results Only Results Only Ver2 Application for Acceptance for Results Only Full Name (First + Middle + Last)* Permanent Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Date of Birth* Email* **PLEASE NOTE ALL INFORMATION IS KEPT CONFIDENTIAL**How many hours a week do you work full time, part time, stay at home:* 70+ 60+ 50+ 40+ Less than 30 What Level of fitness would you rate yourself at currently:* Very fit Moderalty fit Out of shape Very out of shape How many days can you realistically workout per week:* 6 Days 5 Days 4 Days 3 Days 2 Days How long will each session last:*60 Minutes45 Minutes30 MinutesHow would you rate your eating:*I am 100% aware that only good calories go into my body:I eat well 75% of the time and cheat 25%50% I am good 50% not so goodI have no idea how to eat wellWhat is your biggest obstacle to making fitness part of your daily routine:*My jobMy famiyMy motivationEmergency ContactNameEmergency Contact Name/Relationship Please check if Applicable:Advised by Doctor to not excersise>ClientYESNoFamilyYESNoIf Yes DescribeLower BackClientYESNoFamilyYESNoIf Yes DescribeDiabetesClientYESNoFamilyYESNoIf Yes DescribeHigh Blood PressureClientYESNoFamilyYESNoIf Yes DescribeHigh CholestrolClientYESNoFamilyYESNoIf Yes DescribeArthritisClientYESNoFamilyYESNoIf Yes DescribeAsthmaClientYESNoFamilyYESNoIf Yes DescribeHeart ConditionClientYESNoFamilyYESNoIf Yes DescribeStroke/Heart Attackp>ClientYESNoFamilyYESNoIf Yes DescribeHeadaches/MigriainesClientYESNoFamilyYESNoIf Yes DescribeIrregular HeartbeatsClientYESNoFamilyYESNoIf Yes DescribeHearing LossClientYESNoFamilyYESNoIf Yes DescribeCirculatory problemsClientYESNoFamilyYESNoIf Yes DescribeSmoke/tobacco productsClientYESNoFamilyYESNoIf Yes DescribePrescription MedicationClientYESNoFamilyYESNoIf Yes DescribeDo you have any of the following conditions that may limit your activity? (check all that apply) Ankle/Foot Injury Bone Fracture Shoulder/Clavicle Injury Arthritis Low/Back Pain Wrist/Hand Injury Arm/Elbow Injury Knee/Thigh Injury Hip/Pelvic Injury Calcium Deposits Nerve Damage Tennis Elbow Upper Back Injury Head/Neck Injury Other Please Explain:Family SectionHow would you rate any physical activity at work? Very Little Little Active Very Active N/A How would you rate the stress level of your job? Little Modarate Stressful N/A Have you ever had a stress test? Yes No If so, date of recent test: Result: Normal Abnornal Advised by a doctor not to excercise*YesNoWhat was your weight one year ago?Five years ago?Do you follow any special diet at the present time? Yes No If so, what type?What are your personal exercise program goals?*Weight Control/LossStaying in ShapeStress ReductionIncreasing StrenghtCardiovascular ConditioningAre you currently involved in a physical excersise program? Yes No #Days of Fitness (Week) #Minutes of Fitness (Per session Personal Fitness Goals for the next 3 months: Are there any items/issues not mentioned above that should/must be discussed prior to staring this program?What would it take to make fitness rank higher in your life:What are the main reasons you have come to Results Only Fitness today? What are the health and fitness habits you would like to change? Where do you see yourself in 3 months: 6 months: 12 months What is your long-term vision for keeping fitness a high priority in your life?What motivates you?is there anything else you would like to share with us when considering you for this program?AcknowledgementProgram Agreement By signing where indicated below, you irrevocably agree that if Results Only LLC (the “Company” or “we/us”) approves your application and accepts you into the Results Only Program (the “Program”) participant, then this Program Agreement (the “Agreement”) automatically becomes a binding contract between you and the Company; and applies to your participation in the Program. By signing below, you are acknowledging that you have read, agree to and accept all of the terms and conditions contained in this Agreement. We may amend this Agreement at any time by sending you a revised version at the address you provided above. By completing the Application and signing below, you authorize the Company to charge your credit or debit card, or cash your check, as indicated above, as payment for your membership in the Program, if the Company approves your Application and accepts you into the Program. Furthermore, you agree that if you are accepted into the Program, you are responsible for the full payment of fees for the entire course of the Program, regardless of whether you actually attend or complete the Program, and regardless of whether you have selected a lump sum or monthly payment plan. To further clarify, no refunds will be issued and all monthly payments must be paid on a timely basis. We are committed to providing all Program participants with a positive Program experience. By signing below, you agree that the Company may, at its sole discretion, terminate this agreement, and limit, suspend, or terminate your participation in the program without a refund or forgiveness of remaining monthly payments if you become disruptive or difficult to work with, if you fail to follow the Program guidelines, or if you impair the participation of Program instructors or participants in this Program. We respect your privacy and must insist that you respect the privacy of fellow Program participants. By signing below, you agree not to violate the publicity or privacy rights of any Program participant. We respect your confidential and proprietary information ideas, and trade secrets (collectively, “Confidential Information”) and must insist that you respect the same rights of fellow Program participants and of the Company. participants and of the Company. By signing below, you agree (1) not to infringe any Program participant’s or the Company’s copyright, patent, or trademark, trade secret or other intellectual property rights, (2) that any Confidential Information shared by Program participants or any representative of the Company is confidential and proprietary, and belongs solely and exclusively to the participants who discloses it or the Company, (3) you agree not to disclose such information to any person or use it in any manner other than in discussion with other Program participants during Program sessions. By signing below, you further agree that (4) all materials and information provided to you by the Company are its confidential and proprietary intellectual property, belong solely and exclusively to the Company, and may only be used by you as authorized by the Company, and (5) the reproduction, distribution and sale of these materials by anyone but the Company is strictly prohibited. Further, by signing below, you agree that, if you violate, or display any likelihood of violating, any of your agreements contained in this paragraph, the Company and/or the other Program participant(s) will be entitled to injunctive relief to prohibit any such violations to protect against the harm of such violations. By signing you ASSUME THE RISK OF AND RELEASE AND HOLD ROBERT KELLY AND RESULTSONLY,LLC HARMLESS FOR ANY LIABILITY FOR ANY PHYSICAL OR OTHER INJURY OR HARM SUFFURED BY YOU DURING OR AS A CONSEQUENCE OR PARTICIPATING IN THE CLASS/PROGRAM OR PERFORMING ANY SUCH EXERCISE ROUTINES OR ENGAGING IN SUCH OTHER STRENUOS PHYSICAL ACTIVITYAND AGREE THAT NEITHER ROBERT KELLY AND RESULTS ONLY, LLC NOR ANY FACILITY AT WHICH THIS PROGRAM IS BEING HELD NOR ANY OTHER PERSON INVOLVED IN ORGANIZING OR CONDUCTING THIS PROGRAM SHALL HAVE ANY LIABILITY OR RESPONSIBILITY FOR ANY SUCH INJURY OR HARM. You covenant that you shall not now or at any time in the future directly or indirectly, commence or prosecute any action, suit or other proceeding against ROBERT KELLY AND RESULTS ONLY, LLC and its officers, directors, employees, agents, licensees, subsidiaries, consultants, trainers, independent contractors and affiliates, rising out of or relating to the actions, causes of action, claims and demands hereby waived, released or discharged by you. We have made every effort to accurately represent the Program and its potential. Claims of actual results can be verified and examples of actual results provided upon request. The testimonials and examples used are not intended to represent or guarantee that anyone will achieve the same or similar results. Each individual’s success depends on many factors, including his or her background, dedication, desire, and motivation. By signing below, you acknowledge that as with any business endeavor, there is no guarantee that you will achieve the same results as seen in the testimonials as a result of your participation in the Program. By signing below, you also acknowledge that you have represented to the Company that payment of your Program membership fees will not place a significant financial burden on you or your family. For good and adequate consideration, which you acknowledge you have received, you hereby grant, release, and quit claim to ROBERT KELLY AND RESULTS ONLY, LLC to the right and authority to use, sell, reproduce, and distribute, quoted material, biographical information, my photograph, likeness, recorded voice, or videotaped filmed appearances (The Materials) for promotional or advertising purposes or programs as ROBERT KELLY AND RESULTSONLY,LLC in its sole discretion shall deem appropriate. The program instructors are not qualified to provide legal or financial advice, and the information provided to you by the Program instructors is not intended as such. You should refer all legal, and financially related inquiries to appropriately qualified professionals. Date Digital Signature:Printing your First Name + Middle Initial + Last Name will act as your digital signature.