Follow us on:

Home
Class Schedule
Registration
Services

Home
Class Schedule
Registration
Services

Registration Form

To register for classes, please complete the form below. Cost covered by the Highmark Wellness Benefit and Wellness Card. To purchase classes with the wellness card or a credit card, please call 518-925-9844. Have a Great Class!

Contact Us

Program Name

Program Location and Time

First Name

Last Name

Start Date

Highmark Insurance Number

Highmark Insurance Renewal Date

Employer

Date of Birth

Sex

Female

Male

Other

Address (street, city, state, zip)

Phone Number

Email

I understand that in using my Highmark wellness benefit, my insurance will be billed for the entire program, regardless of how many classes I attend. Unattended classes are forfeited and will not be rolled over. *

Yes

No

Has your doctor ever said that you have a heart condition and 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

Do you lose balance, experience chest pain, feel dizzy, or lose consciousness?

Yes

No

Do you have a bone or joint problem that could be made worse by physical activity?

Yes

No

Are you taking blood pressure or heart medication?

Yes

No

Do you know of any other reason why you should not do physical activity?

Yes

No

Free Text

If you answered NO to all PAR-Q (Physical Activity Readiness Questionnaire) questions above, you can be reasonably sure that you can start becoming more physically active – begin slowly and build up gradually. ALWAYS CHECK WITH YOUR DOCTOR BEFORE STARTING A NEW PHYSICAL ACTIVITY.

Signature

Date

Your registration has been received. Your insurance will be billed after the first class. A welcome email will be sent closer to the start of the program. We hope you enjoy your classes. THANK YOU!

Oops, there was an error sending your message.
Please try again later.

If you would prefer to print and mail your registration form, click here.

Home | Class Schedule | Registration | Services