USANA Health Sciences

Nutritionals You Can Trust

www.harvellfitness.USANA.com

Training Programs and Rates

Program I – Get in Shape

Program II – Train for Competition

Other Information You Should Know

Client Application

Name:
Birth Date:
Age:
Address:
Home Phone:
Cell Phone:
E-mail:
Emergency Contact Person and Phone Number:

Check the program you want:
	Program I
	Program II
Do you know, or have you had in the past:
	History of heart problems, chest pain, or smoke
	Increased blood pressure
	Any chronic illness or conditions
	Difficulty with physical exercise
	Advise from physician not to exercise
	Recent surgery (past 12 months)
	Pregnancy (now or within last three months)
	History of breathing or lung problems
	Muscle, joint, or back disorder, or any previous injury still affecting you
	Diabetes or thyroid conditions
	Cigarette smoking habit
	Obesity (more than 20% over ideal weight)
	History of heart problems in immediate family
	Hernia, or any condition that may be aggravated by lifting weights
	Other

Monthly payment for each program should be mailed (check or bank draft) to the address listed below:

Samuel Harvell	E-mail: samuelharvell@sbcglobal.net
1329 46th Avenue	Office: 415-681-7908
San Francisco, CA 94122	Cell: 415-726-4487