Health Evaluation Form

Personal Info

Name *

Date of Birth *

Gender *

Female Male

Weight *

Email *

Cell Phone

Address *

Emergency Contact *

Relationship *

Emergency Contact Phone *

I understand that by following the eating program/workout program to the best of my ability will yield greater results. I also understand that by not drinking any alcoholic drinks except for one day per week (cheat day) will yield results at an accelerated rate. I agree to hold harmless Travis Garza/TLC Fitness, Inc., and all of his employees or agents free from any and all injuries, losses, damages, and liability occurring from my participation in the activity for which I have enrolled. I also agree to be photographed/videotaped and release the use of the photographs/videos for publicity in Travis Garza’s ‘Fat Loss Camps’ and TLC Fitness, Inc.’s publications and other marketing tools.

Signature *

If participant is a minor (age 13-18), parental consent has been give for the minor's participation. Please provide digital signature of parent or legal guardian.

Signature Date *

By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

TravisGarza.com

PO Box 414
Edmond, OK 73083

405-820-3813

info@travisgarza.com

ALL I ASK MY CLIENTS TO DO IS SHOW UP AND FOLLOW MY INSTRUCTIONS.

Your one stop Garza supplement shop in Edmond, OK

Garza's Sports Nutrition

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