Adaptive Fitness Registration
Adaptive Fitness Registration
Date *
Your answer
Client's Name *
Your answer
Address *
Your answer
Organization *
Your answer
Phone Number *
Your answer
Date of Birth *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Address *
Your answer
Parent/Guardian Home Phone Number *
Your answer
Parent/Guardian Cell Phone Number *
Your answer
Parent/Guardian Email *
Your answer
Relationship to the Child *
Your answer
Child’s Physician’s Name *
Your answer
Child’s Physician’s Phone Number *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Relationship to Child *
Your answer
Is texting okay? *
Does your child have any allergies? *
If so, what are the known allergies?
Your answer
What medications is your child taking? *
Your answer
Does your child experience high blood pressure? *
Does your child experience seizures? *
If yes, how often?
Your answer
Does your child suffer from any known cardiopulmonary problems? *
Your answer
Has your child had any broken bones in the past two years? *
Your answer
Has your child had surgeries or medical complications in the past 5 years? *
Your answer
Are there any known contraindications to exercise/ physical exertion? *
Your answer
Limitations to Stretching (please check all that apply): *
Required
Are there any limitations to any Muscle strength activation movements? Please check all that apply: *
Required
What would you like us to know about your child? *
Your answer
Are there any limitations that you would like to express about your child?
Your answer
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