Client Intake Form – Retreat Client Intake FormTo better serve your health and fitness needs, we ask that you please take a few minutes to complete this form. All information is confidential and will only be used by the instructor to better support your needsName* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Would you like to be included in emails / newsletters regarding general updates? You can unsubscribe at any time if you change your mind. Yes No Phone (Home)Phone (Work)Phone (Mobile)Best number to reach you?* Home Work Mobile Emergency Contact - Name* First Last Emergency Contact Phone Number*What specific fitness or health goals do you hope to achieve?Please list all previous and current physical activities/exercise.Describe your present physical condition. Do you currently experience pain?Please list any significant injuries, surgeries, medical treatments, ailments, pregnancies, or illnesses.*Have you been diagnosed with any of the following:* Osteopenia or Osteoporosis High blood pressure Fibromyalgia Have you consulted with your physician regarding an exercise program?*How did you hear about our retreat?Agreement of Release & Waiver of LiabilityName First Last Please read carefully and check the box below to agree with the following: I understand that if I must cancel a scheduled appointment or class, I must notify Abundant By Nature (ABN) or ABN instructor, 24 hours in advance or I will be held responsible for payment. We respect and honor your time and we ask you to do the same. I will receive information and instruction while participating in classes, health programs, sessions and workshops offered by Abundant By Nature LLC (ABN). I recognize that this class will require physical exertion, which may be strenuous and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician prior to starting any exercise program and have been approved for physical activity. I understand that it is my responsibility to consult with a physician regarding the class at ABN. I represent and warrant that I am physically fit and have not medical conditions that would prevent my full participation in the class, health program, session or workshop. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participation in ABN programs. I knowingly, voluntarily and expressly waive any claim that I may have against the instructors or ABN for injuries or damages that I may sustain as a result of my participation in classes, health programs, sessions and workshops offered by Abundant By Nature LLC (ABN). Heirs, my legal representative and I forever release and waive any liabilities against CHP and its affiliates for any injury or death incurred by my voluntary participation in classes, health programs, sessions and workshops offered by Abundant By Nature LLC (ABN).I agree to the above.* Yes I have read the above release and waiver of liability and fully understand their contents. I voluntarily agree to the terms and conditions stated above.Signature*Date* Date Format: MM slash DD slash YYYY Please select today's date.