* Denotes questions that require an answer

Name

Question Title

* 1. Name

Email

Question Title

* 2. Email

Contact Telephone Number

Question Title

* 3. Contact Telephone Number

Date of Birth.

Question Title

* 4. Date of Birth.

In Case of Emergency

Question Title

* 5. In Case of Emergency

How did you hear about us?

Question Title

* 6. How did you hear about us?

Are you pregnant?

Question Title

* 7. Are you pregnant?

Do you have any of the following medical conditions?

Question Title

* 8. Do you have any of the following medical conditions?

  Yes No
A heart condition
Diabetes - Type 1 or 11
Arthritis
Asthma
High Blood Pressure
High Cholesterol
Epilepsy
Osteoporosis
Endometriosis
Have you had any major operations
Do you ever get chest pains?
Do you ever feel dizzy?
Do you take any medication?
Have you smoked in the last 5 years?
Do you have any injuries or issues with joints or muscles in the following areas?

Question Title

* 9. Do you have any injuries or issues with joints or muscles in the following areas?

  Yes No
Ankles
Knees
Hips
Back
Shoulders
Neck
Elbows
Wrists
I know of no medical reason why I should not participate in an exercise program. I understand that I take part at my own risk and I waive any legal recourse for damages to myself or property arising from participation.

Question Title

* 10. I know of no medical reason why I should not participate in an exercise program. I understand that I take part at my own risk and I waive any legal recourse for damages to myself or property arising from participation.

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