Recess Questionnaire
Please fill out this questionnaire to register for Recess (kids fitness class) for each child participating. Upon filling this out, you will receive an invoice from Bolte Fitness via an email from Stripe for the first month's session. Please pay the invoice as soon as possible to receive important class information (address, etc.) and to confirm your child's spot. Your spot WILL NOT be confirmed until paid as class size is limited.
We look forward to getting the opportunity to coach your kid!!
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Child's Name
Preferred Pronouns
Email Address for Class Updates
Phone Number for Class Updates
Child's Date of Birth
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Emergency Contact (Name, Phone Number, Relationship)  Please list multiple if needed.
Physician Name and Phone Number
Is your child currently under a doctor's care?  If yes, explain.
When was the last time your child had a physical examination?  
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Has your child had any surgeries? If yes, explain.
Does your child have a history of any cardiovascular issues? If yes, explain.
Does your child have any medical condition, pain, injury, or concern? If yes, explain.  
Do they take any medications on a regular basis?
Does your child have any allergies? Please list all.
Does your child have any movement restrictions? If so, please explain.
Has your child been "cleared" by their physician for physical activity?
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What are you hoping your child will get out of Recess?
Is there anything else your child's coach should know?
In checking the box below, I, the parent/guardian of the aforementioned child, affirm that I have read this form in its entirety and I have answered the questions accurately and to the best of my knowledge. I understand that my child is responsible for monitoring him or herself throughout any activity, any should any unusual symptoms occur, would ease participation and inform the instructor. If medical clearance must be obtained before my child’s participation in an exercise session, I agree to contact the child’s physician and obtain written permission prior to the commencement of the exercise activity, and that the permission be given to the instructor.
Date
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