Class Name & Time
Class Location
Name of Person Registering
Your Preferred date to start class
Insurance Company
Insurance ID number
Date of Insurance Benefit Renewal
Employer
DOB
Sex
Address: street, city & zip code
Phone
Email
Patient Responsibility
I am registering for the above Program, utilizing the ‘wellness’ benefit under my insurance plan. I understand Fitness Professionals On Demand will be billing my Insurance Company to be applied against my ‘wellness’ benefit.
I understand that I may be responsible for payment for services if it is determined by my insurance company to be non-covered services if I have an insurance plan without wellness benefits or if my insurance contract has terminated. I understand that under these circumstances services I am financially responsible for payment of these non-covered services.
Signature & date to confrim you understand your above pateint respsonibility.
Waiver
I do not have any medical problems that would put me at medical or physical risk from participating in this class. If I had a doubt, or if I have any chronic or acute medical problems, then I have checked with my doctor and obtained a medical release. I have given my instructor a copy of this medical release.
Signature & date confirming my agreement to waiver.
Physical Activity Readiness Questionnaire (PAR-Q) and You Questionnaire
If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. (*ACSM’s Health/Fitness Facility Standards and Guidelines, 1997 by American College of Sports Medicine)
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
If you answered YES to one or more questions Talk to your doctor by phone or in person BEFORE you start becoming much more physically active. If you answered NO to all PAR-Q questions, you can be reasonably sure that you can start becoming much more physically active – begin slowly and build up gradually
