Fitness Professionals On Demand - Registration Form1

Fitness Professionals On Demand,LLC
7 Locust Lane Clifton Park, NY 12065
cox@nycap.rr.com
518-505-2669

Home
About Us
- Testimonials
Bride-to-Be
BSNENY
Classes
- OnlineClasses
Corporate Wellness
- Fitness Survey
Personal Training
Registration
- Non- BS Registration
- BSNENY Registration
Weight Management

About Us Class Schedule Class Registration Form Corporate Wellness Personal Training BlueShield of Northeastern NY Members

Class Name & Time
Class Location
Name of Person Registering
Your Preferred date to start class
Insurance Company
Insurance ID number
Employer
DOB
Sex		Female Male
Address: street, city & zip code
Phone
Email
Payment mailed to address above		___Yes___ No
Waiver		I do not have any medical problems that would put me at medical or physical risk from participating in this class. If there is any doubt or if I have any chronic or acute medical problems I have checked with my doctors and obtained a medical release and 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?		Yes No
Do you feel pain in your chest when you do physical activity?		Yes No
In the past month, have you had chest pain when you were not doing physical activity?		Yes No
Do you lose your balance because of dizziness or do you ever lose consciousness?		Yes No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?		Yes No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?		Yes No
Do you know of any other reason why you should not do physical activity?		Yes No
		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

Non- BS Registration Form