Find A Personal Trainer in Austin, Texas Exercise Program Health Consent Date First Name Last Name Street Address Address Line 2 City State / Province State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansansCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFlorida ZIP / Postal Code Country CountryAlabamaAlaskaAmerican SamoaArizonaArkansansCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFlorida Email Address Phone (cell) Phone (home) Signature of Client Date Signature of Witness Date Submit