CoachShellie Boot Camp Registration Form
First Name *
Your answer
Last Name *
Your answer
Email Address *
Your answer
Address Line 1 *
Your answer
Address Line 2
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Mobile Phone (Texting will be used to notify about any potential changes to class schedule or cancellations) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Height
Your answer
Weight
Your answer
Emergency Contact Name/Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
How did you hear about us?
If referred, by whom?
Your answer
What are your specific fitness/health goals for boot camp? (Please, check all that apply.)
PAR-Q
PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people, physical activity should not pose any problems or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these few questions. Please read them carefully and check YES or NO. If you answer yes, please explain.
Has your doctor ever said you have heart trouble? *
Do you frequently have pains in your heart and chest? *
Do you often feel faint or have spells of severe dizziness? *
Has a doctor ever said your blood pressure was too high? *
Has your doctor ever told you that you have a bone or joint problem(s), such as arthritis that has been aggravated by exercise, or might be made worse with exercise? *
Is there a good physical reason, not mentioned here, why you should not follow an activity program even if you wanted to? *
Are you over age 60 and not accustomed to vigorous exercise? *
Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness? *
Are you currently taking any medications? If YES, please specify in space provide below. *
Do you currently have a disability or a communicable disease? If YES, please specify in space provided below. *
For any YES answers, please use space provided below to explain.
Your answer
Are you able to participate in physical activity?
If you answered NO to all questions above, it gives a general indication that you may participate in physical and aerobic fitness activities and/or fitness evaluation testing. The fact that you answered NO to the above questions is no guarantee that you will have a normal response to exercise. If you answered YES to any of the above questions, then you may need written permission from a physician before participating in physical and aerobic fitness activities and/or fitness evaluation testing.
By checking "I Agree", you agree to the Informed Consent Waiver/Release and Hold Harmless Agreement found at this link http://coachshellie.com/waiver/ *
Submit
Never submit passwords through Google Forms.
This form was created inside of Coach Shellie. Report Abuse