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Full legal name *
*
Preferred name / pronouns
Date of birth *
*
Month
Month
Day
Year
Mobile phone *
*
Email *
*
Street address *
*
City, state, ZIP *
*
Emergency contact — name, relationship, and phone *
*
Small-group plan
5 classes — $100 one-time
8 classes — $130/mo
12 classes — $180/mo
Unlimited — $230/mo
Insurance
One-on-one training plan
6 sessions — $175/30 days
8 sessions — $249/30 days
12 sessions — $349/30 days
16 sessions — $499/30 days
Additional services of interest (Nutrition, Styku 3D, InBody, Other)
Preferred contact method
Embrace Body app
Text
Email
Phone
How did you hear about Embrace Body?
Auto-renewal initials (leave blank if not on a recurring plan) — BY INITIALING, I agree my plan will automatically renew monthly and charge my payment method each month until I cancel
Diagnosed or treated conditions — select all that apply
Heart/circulatory
Blood pressure
Diabetes/blood sugar
Respiratory
Joint/back pain
Neurologic
Pregnancy/postpartum
Other
None
Conditions, diagnoses, surgeries, hospitalizations, medications, supplements, and allergies or adverse reactions
Primary healthcare provider, provider phone, and date of last physical
PAR-Q 1: Has a healthcare professional ever told you that you have a heart condition or should only exercise under medical guidance?
Yes
No
PAR-Q 2: Do you feel chest pain, unusual pressure, or significant shortness of breath during activity?
Yes
No
PAR-Q 3: In the past month, have you had chest pain while not exercising?
Yes
No
PAR-Q 4: Do you lose balance because of dizziness, or have you lost consciousness?
Yes
No
PAR-Q 5: Do you have a bone, joint, back, or other condition that could worsen with exercise?
Yes
No
PAR-Q 6: Are you currently pregnant, recently postpartum, or advised to modify activity?
Yes
No
PAR-Q 7: Is there any other reason you should not begin or increase physical activity today?
Yes
No
Primary goals — select all that apply
Strength
Body composition
Weight management
Energy
Mobility
Sports performance
Healthy eating
Accountability
Confidence
Stress support
Describe your top three goals and why they matter to you right now
Current activity level
Mostly inactive
Light
Moderate
Very active
Athlete
Exercise experience, current routine, and current pain, injuries, or limitations
Lifestyle: average sleep (hrs), stress level (0-10), water intake/day, average steps/day, and any barriers to consistency
Nutrition priorities — what support are you seeking?
Balanced meals
Protein
Hydration
Meal planning
Portions
Sports fueling
Weight goals
Energy
Grocery skills
Accountability
Nutrition goals, food allergies/intolerances, dietary preferences or restrictions, and a brief description of a typical day of eating
Health and eating history — select all that apply
GI symptoms
Difficulty chewing/swallowing
Low appetite
Food insecurity
Disordered-eating concern
Recent major weight change
None
Prefer to discuss privately
Policy 1 initials * — Payment, Deposits & Refunds: All fitness plans are final sale and nonrefundable. Payment due before service. Missed or unused services do not create a refund.
*
Policy 2 initials * — Booking & Scheduling: Fitness booking opens up to four days in advance. Same-day booking closes three hours before session. All bookings must be confirmed before attendance.
*
Policy 3 initials * — Cancellations, Emergencies & No-Shows: Cancel at least one hour before start time. Late cancellations incur a $10 fee. A no-show may count as used and incur a $10 fee. Late arrival does not extend the session.
*
Policy 4 initials * — Session Use, Expiration & Rollover: Sessions must be used within the 30-day cycle. Only ONE UNUSED SESSION may roll into the next cycle. All additional unused sessions expire.
*
Policy 5 initials * — Pauses, Expired Plans & Account Status: A pause of up to three weeks may be approved with advance notice. An expired plan cannot be renewed; client must enroll in a current plan.
*
Policy 6 initials * — Assessments & Plan Benefits: STYKU 3D IS NOT INCLUDED WITH A 5-CLASS PACKAGE OR INSURANCE MEMBERSHIP. Included benefits have no cash value.
*
Policy 7 initials * — Insurance, Wellness Benefits & Client Responsibility: Eligibility verification is not a guarantee of payment. Client is responsible for copays, denied claims, and noncovered services.
*
Policy 8 initials * — Communication & App Scheduling: Scheduling and routine questions go through the Embrace Body app. The app is not monitored for emergencies; call 911 for an emergency.
*
Policy 9 initials * — Safety, Conduct & Shared Space: Follow coaching instructions, facility rules, and respectful conduct standards. Report pain, dizziness, injury, pregnancy, or medication changes promptly.
*
Policy 10 initials * — Scope, Referrals & Updates: Fitness and nutrition coaching are not medical diagnosis or treatment. Policies may be updated with notice.
*
Plan type — select all that apply
5-class package
Insurance membership
One-on-one training
Other small-group plan
Policy 11 initials * — One-on-One Training Plans: Plans use a 30-day billing cycle. Auto-renewal is OPTIONAL and requires the front-page opt-in. Requested times are not guaranteed. Late-canceled or missed sessions may count as used.
*
Policy 12 initials * — Small-Group Memberships: AUTOMATIC RENEWAL IS OPTIONAL for recurring small-group plans. Not attending or not booking does not by itself cancel the plan. SC cancellation rights remain unchanged.
*
Policy 13 initials * — One Unused Session Rollover: Only ONE UNUSED SESSION may carry into the next cycle on an eligible active plan. The rollover has no cash value. No rollover remains after cancellation or expiration.
*
Policy 14 initials * — No Refunds, Cancellations & Current Plans: One-on-one plans, small-group memberships, and current-cycle charges are NONREFUNDABLE except as required by law.
*
Training plan acknowledgment — full legal name *
*
Training plan acknowledgment — signature (type full legal name) *
*
Training plan acknowledgment — date *
*
Liability waiver — client full legal name *
*
Liability waiver — client initials *
*
Liability waiver — date *
*
Liability waiver — signature (type full legal name) *
*
Assessment(s) authorized
Styku 3D
InBody
Combined wellness assessment
Not applicable
Assessment consent — client full legal name, initials, date, and signature (type full legal name) *
*
Communication permission — select all channels you consent to
App notifications
Text/SMS
Email
Phone/voicemail
Photo/media permission
YES — I give permission for photos/media of me
NO — I do not give permission
If YES — approved uses (select all that apply)
Social media
Website/app
Print marketing
Internal celebration
Testimonial
Identity choice for media
May show face and name
No name
No face
Ask me before each use
Privacy & media — client full legal name, date, initials, and signature (type full legal name) *
*
Primary wellness goal and plan start date *
*
Commitment form — client full legal name *
*
Commitment form — signature (type full legal name) *
*
Commitment form — date *
*
South Carolina cancellation notice — client full legal name *
*
South Carolina cancellation notice — signature (type full legal name) *
*
South Carolina cancellation notice — date *
*
Submit Membership Form
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