REGISTRATION FORM

PART ONE

Name:

Date:

Gender
male female

Address:

City, State, ZIP

Enter Contact Email Address:

PART TWO

Height:

Weight:

Date of class you'll be attending:

Type of class you'll be attending:

Total price of program:

Rate your fitness level: (1=Low/None, 2=Average, 3=Fit, 4=Very Fit)

Rate your daily activity level: (Light=1.3, Moderate=1.5, Heavy=1.7)

Physician’s Name:

Physician’s Phone ( ):

Person to contact in case of emergency:

Emergency contact phone number:

Are you taking any medications or drugs?
yes no

If so, please list medication, dose, and reason.

Does your physician know you are participating in this exercise program?
yes no

Enter physician phone number:
PART THREE

Do you now, or have in the past:
yes no - History of heart problems, chest pain, or stroke

yes no - Increased blood pressure

yes no - ANY chronic illness or condition

yes no - Difficulty with physical exercise

yes no - Advice from physician not to exercise

yes no - Recent surgery (last 12 months)

yes no - Pregnancy (now or within last 3 months)

yes no - History of breathing or lung problems

yes no - Muscle, joint or back disorder, or any previous injury still affecting you

yes no - Diabetes or thyroid condition

yes no - Cigarette smoking habit

yes no - Obesity (more than 20% over ideal body weight)

yes no - Increased blood cholesterol

yes no - History of heart problems in immediate family

yes no - Hernia or any condition that may be aggravated by lifting weights

Please explain any “yes” answers:

Waiver:
By checking the 'Submit' button below, I agree that I, the undersigned, have read, understand, and have answered the above health/medical survey questions fully and truthfully. I am aware of my responsibility to consult with my personal physician regarding my medical fitness to engage in a strenuous exercise and a nutritional support program. I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the participating training facility, and the fitness trainer administering this instrument for any and all injuries suffered while following the training and/or nutrition program provided to me.

*Registration and payment must be turned in and waiver must be signed prior to participation.