Registration Form

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

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

Has your doctor ever said that you have a heart condition and should only do physical activity recommended by a doctor?

Yes

Do you feel pain in your chest when you do physical activity?

Yes

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

Yes

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

Yes

Are you taking blood pressure or heart medication?

Yes

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

Yes

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

THANK YOU!

Your registration has been received. Your insurance will be billed for the entire program.

If you are not using insurance, please remit payment to: Rockower Wellness, 156 South Street, Glens Falls, NY 12801. PayPal or Venmo: @rockowerwellness

A welcome email will be sent closer to the start of the program. We hope you enjoy your classes. THANK YOU!

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

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