Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Birthdate *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Desired Drop-in Date *

MM

DD

YYYY

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

2. Do you feel pain in your chest when you do physical activity? *

Yes

No

3. In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

4. Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?

Yes

No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition? *

Yes

No

7. Do you know of any other reason why you should not do physical activity? *

Yes

No

I have read and accept the Informed Consent & Assumption of Risk clause above, and certify that all my answers are true and correct. *

Yes

Today's Date *

MM

DD

YYYY