Personal Date Of Birth Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Contact Address
Medical Do you have a history of any of the following medical conditions? Medical
Please rate your pain in each area on a scale of 0 ( no pain ) to 10 ( worst pain possible):
Please rate your current goals form 1( most important) to 6 (least important):
WAIVER OF LIABILITY FOR FACILITY AND USE
"I hereby understand and acknowledge that this waiver includes any training, programs, dietary recommendations, supplement recommendations, any and all recommendations, any and all advice, any and all referrals, as well as any events or participation ion any activity outside of the Neuro Force One (NF1), a Deleware C-corporation, facility. Such activities may expose me to many inherent risks, including accidents, injury, illness, or even death. I assume all risk of injuries associated with participation including, but not limited to falls, contact with other participants, the effects of the weather, including high heat and/or humidity and all other such risks being known and appreciated by me.
I hereby acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with participation in activity. I acknowledge that I am physically fit and mentally capable of performing the physical activity I choose to participate in. After having read this waiver and knowing these facts, and in consideration of acceptance of my participation and NF1 furnishing services to me, I agree, for myself and anyone entitled to act on my behalf, to HOLD HARMLESS, WAIVE AND RELEASE NF1, its officers, agents, employees, organizers, representatives, and successors from any responsibility, liabilities, demands, or claims of any kind arising out of my participation in NF1 training, programs, assessments, dietary recommendations, supplementation recommendations, any and all recommendations, any and all advice, any and all referrals, and/or events.
By my signature I indicate that I have read and understand this Waiver of Liability. I am aware that this is a waiver and a release of liability and I voluntarily agree to its terms."
(Parent's Signature if under 18 years of age)
I represent that I have legal capacity and authority to act on behalf of the minor named herein. IMAGE RELEASE FORM
I am at least eighteen years old and competent to understand, consent to and authorize the
following. I hereby irrevocably consent to and authorize:
The use by NEURO FORCE ONE INC., a Delaware C-Corp (
“NF1”) of any and all
photographs, video, voice recordings, or other media taken of me by NF1 or its employees,
contractors, or agents, including derivative works thereof (collectively, the “Images”); Any reproduction of the Images in any form in any media whatsoever, whether now
known or hereafter created, throughout the world in perpetuity; and
The use of my name or likeness in connection with the exhibition, distribution,
merchandising, advertising, and/or publicizing of Images by NF1.
I hereby release and discharge NF1, its managers, members, officers, employees, licensees,
representatives, and affiliates from any and all claims, actions, suits or demands of any kind
or nature whatsoever, in connection with the use or reproduction of the Images.
I understand and agree that NF1 will be the exclusive owner of all rights (including
copyrights) in and to the Images in perpetuity and in any medium now known or hereafter
developed. I understand and agree that NF1 may license third parties to use the Images in any
manner NF1 may determine in its sole discretion, without any obligation to me. I hereby
waive any right that I may have to inspect and/or approve the use of the Images or any
reproductions thereof, by NF1. Address
AZ Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
Cancellation/Late Policy for Training:
NF1 maintains a
12 hour cancellation/rescheduling policy. If a session is not canceled or rescheduled within 12 hours it will be documented as a “no-show” and it will result in a loss of a session and be charged at 100% of the session cost.
Each client will be granted 1 Emergency No Show/Cancellation (ENSC) per quarter. ENSC’s are cancellations made with less than 12 hours notice or a no show due to an emergency. ENSC’s will not be documented as a “no-show” and the client will not be charged for the session.
Any client that exceeds 3 No-Shows per quarter will be subject to dismissal from the NF1 training program and will not be granted a refund for any prepaid and/or unused training sessions.
If a client shows up, up to 15 minutes after the start of their scheduled training session time they will be considered a “late show”. If a client exceeds 10 late-shows per quarter they will be subject to dismissal from the NF1 training program and will not be granted a refund for any prepaid and/or unused training sessions.
All NF1 training sessions include a 20 minute “grace period”. The grace period indicates a 20 minute window from the start of the scheduled session time in which the client can still retain the session if they show up late. If a client shows up after the 20 minute grace period it will result in loss of a training session and the client will be charged 100% of the training session cost. Zip Code
* Performance Questionnaire