BOYS & GIRLS | 5-14
Momentum Kids

Designed specifically for neurodivergent kids.

Thursday: 4:00PM or 4:30PM
Saturday: 9:30 or 10:00 AM

Read: Momentum Kids at Cynergy Training: Building Strength, Confidence & Emotional Skills

Learn more.

Momentum Kids

No refunds. Read policies. NOTE: Please be sure you complete your registration. If you did not receive an email confirmation, you're registration did not go through.

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Company

This field is for validation purposes and should be left unchanged.

Registration*

Free Intro Evaluation

2x Week

1x Week

Drop In

1:1 Coaching

Drop In Day & Time*

Please select the day and time for your drop in.

Thursday @ 4:00 PM

Thursday @ 4:30 PM

Saturday @ 9:30AM

Saturday @ 10:00AM

Drop In Date*

Please indicate the date you will be joining us. Please allow at least 24 hours notice, requested date and time may not be available.

Which Day of the Week?

Please select which day you would like to attend.

Thursday

Saturday

Thursday Time

Select the class time for Thursday.

Thursday @ 4:00 PM

Thursday @ 4:30 PM

Saturday Time

Select the class time for Saturday.

Saturday @ 9:30 AM

Saturday @ 10:00 AM

NOTE: After you submit your registration, the coach will contact you to coordinate the best day & time for your 1:1 Coaching session. Please leave any requests in the comments section at the bottom of the form.

Before joining a class, every child is invited to a complimentary evaluation. This casual meeting allows us to connect, assess their current level, and find the best program fit. If appropriate, they may be invited to a test class following the evaluation—giving both the child and parent a chance to experience the program before officially joining.

Athlete's Name*

(Please indicate child's name here.)

First Last

Parent's Name*

First Last

Parent's Email*

Enter Email Confirm Email

Best Phone*

Please indicate the best number to reach you.

Child's Age*

Questionnaire, Waiver and Medical History forms*

If you have already completed the Questionnaire, Waiver and Medical History forms in the last 12 months, please indicate below.

No, I have not completed these forms in the past year.

Yes, I have completed these forms in the past year.

Questionnaire

Briefly describe your child’s main form of communication (vocal, AAC, points/gestures)?*

Does your child independently follow whole group instructions?*

Yes

Other

Has your child ever received ABA services before?*

Yes

If yes, for how long and in what setting (center/home/community)?*

Please also include, if any, speech, OT, or PT services.

Does your child have any challenging behaviors (aggression, tantrums, etc)?*

Yes

Other

Please provide a small description of each and any triggers/antecedents to them (what happens prior to them occurring).*

Please describe what typically occurs after the behavior.*

Any coping strategies?*

Does your child have any preferences?*

What are their favorite movies or shows?*

What are their favorite toys?*

What is their favorite music/artist?*

Do you have any skills or goals outside of fitness/exercise you would like your child to build on? (social skills, fine motor/gross motor, communication, etc)*

How did you hear about Momentum Kids?*

Cynergy Training Member

Friend

Online Search

Facebook

Instagram

Drive By

Repeat

Other

Cynergy Training Member's Name

Friend's Name

Additional Comments or Information

Please provide any additional information here that you think is necessary for the instructors to know.

Medical History

Physical activity should not pose any problem or hazard to the majority of people. The following questions are designed to identify the small number of adults for whom physical activity might be inappropriate or those who should seek medical advice prior to initiating a fitness program or other change in their physical activity levels.

Is your child accustomed to vigorous exercise?*

Yes

Has your child ever been diagnosed with Type I or Type II Diabetes?*

Yes

Has your child had any major or minor surgery in the past 3 months?*

Yes

If yes, please describe.*

Has your child ever seen a chiropractor or physical therapist for any condition?*

Yes

If yes, please describe.*

Has your child been hospitalized in the last 2 years?*

Yes

If yes, when and for what reason?*

Does your child have shortness of breath or labored breathing, with or without pain?*

Yes

If yes, describe under what conditions.*

Does your child experience unexplained heart palpitations or been diagnosed with a heart murmur or irregular heartbeat?*

Yes

Has your child ever been diagnosed with high blood pressure?*

Yes

If yes, when?*

Waiver Release

I have volunteered to participate in a fitness program provided to me by Cynergy Training which may include, but may not be limited to, resistance training and aerobic or cardiovascular exercise. In consideration of Trainer’s agreement to instruct and train me, I do here now and forever release and discharge and hereby hold harmless Trainer and her respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT BELONGING TO TRAINER OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT; (3) AND/OR NEGLIGENT INSTRUCTION OR SUPERVISION.

I have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity. I also have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved.

I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death. I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed.

If I have chosen not to obtain a physician’s consent prior to beginning this fitness program with Trainer, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST TRAINER FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.

Cynergy Training may use photography and video during regular classes and training events. These photos may be used in email campaigns or advertisements. If you DO NOT want your image to appear in print or in video, please include a note in the comments section at the bottom of this form.

This form is an important legal document that explains the risks you are assuming by beginning an exercise program. It is critical that you have read and understand this document completely. If you do not understand any part of this document, it is your ultimate responsibility to ask for clarification prior to signing it.

Waiver Release Approval*

I have read and understand the Waiver Release information.

Additional Comments

Notes/Updates

Please include any notes or updates here if necessary.

BOYS & GIRLS | 5-14 Momentum Kids

Momentum Kids

Questionnaire

Medical History

Waiver Release

Additional Comments

BOYS & GIRLS | 5-14
Momentum Kids