Fitness Professionals On Demand - General Registration

Follow us on:

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!

Program Name

Program Location/Time

First Name

Last Name

Start Date

Insurance Company

Insurance ID (Highmark members only)

Insurance Renewal Date (Highmark members only)

Employer

Date of Birth

Sex

Female

Male

Other

Address (street, city, state, zip)

Phone Number

Email

Payment mailed (non-Highmark members only)

Yes

No

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 have chest pain when not doing physical activity?

Do you lose balance, 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

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

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

Home | Class Schedule | Registration | Shop | Services