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REMOTE TRAINING

Raise Your Game

The form below is part of your initial intake.
Your coach will contact you and use this information as a foundation to provide the best program for you to achieve your goals. Once submitted, you will be contacted by a coach to schedule your intake consultation.

"*" indicates required fields

Personal

Date Of Birth

Contact

Address

Medical

Do you have a history of any of the following medical conditions?

Please rate your pain in each area on a scale of 0 ( no pain ) to 10 ( worst pain possible):

Goals

Please rate your current goals from 1( most important) to 8 (least important):

Performance Questionnaire

If you play or participate in any competitive sports please fill out the information below.

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 in any activity outside of the Neuro Force One (NF1), a Delaware 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:

  1. 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”);
  2. Any reproduction of the Images in any form in any media whatsoever, whether now known or hereafter created, throughout the world in perpetuity; and
  3. 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.

I agree to the terms and conditions.*
This field is for validation purposes and should be left unchanged.

9096 E. Bahia Dr. Unit 108
Scottsdale, AZ 85260

480-428-4112

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