Customer Registration Form

Customer Name

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Customer E-mail

example@example.com

Mobile Number

Emergency Contact Name & Surname

Emergency Contact Number

Branch you would like to join?

When would you like to start?

Date

How many sessions would you like to join per week?

Do you have any medical condition, disorders, allergies, etc? If yes, please state

Are you pregnant or have you given birth in the last 6 months?

YesNo

Have you recently undergone surgery?

YesNo

If yes, please provide details.

Are you on any medication that may affect your ability to exercise?

YesNo

Do you smoke?

YesNo

Do you drink more than 3 alcoholic beverages per week?

YesNo

If you have a goal weight, please state your current weight:

If you have a goal weight, please state your desired weight:

What is the biggest challenge of reaching your goal?

What are the areas your would like to target on your body?

Any additional information you would like us to know?

Would you please be so kind to pop us the email address of one friend you would like to refer?

Sweat.Smile Fitness & Yoga Registration Form