YMCA Body Composition Analysis Registration

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First Name* This field is required.

2

Last Name* This field is required.

3

Email* This field is required.

example@example.com

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Phone Number* This field is required.

Please enter a valid phone number.

5

How did you hear about the event?* This field is required.

YMCA Staff Member

social media

word of mouth

Other

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Which YMCA location are you a member of?

Freehold

Red Bank

Old Bridge

Toms River

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What is your current fitness goal?* This field is required.

Fat Loss

Muscle Gain

Conditioning

Improve Overall Health (Heart, Lungs, Muscles)

8

Do you have a cardiac arrythmia (A-fib, etc.) and/or a pacemaker?* This field is required.

YESNO

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I hereby grant Atlantic Physical Therapy Center permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.I understand and agree that all photos will become the property of the Atlantic Physical Therapy Center and will not be returned.I hereby irrevocably authorize Atlantic Physical Therapy Center to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.I hereby hold harmless, release, and forever discharge Atlantic Physical Therapy Center from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:* This field is required.Click yes if okay to photograph / no to opt out:

YESNO

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Preferred TimeWe will do our best to accommodate your preferred time!

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Please note that your payment for the body composition analysis ($25 BOGO) will be processed by the YMCA branch you visit.

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Signature of Client (Parent/Guardian if under 18):* This field is required.

Clear