Fitness Class Registration Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
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Fitness Enrollment Information
Sessions Per week
Please Select
Once a week
2x a week
3x a week
4x a week
5x a week
Program
Please Select
Cardio Program
Muscular Strength Program
Endurance Program
Body Flexibility Program
Do you wish to have a personal coach?
Please Select
Yes
No
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Self Assessment Information
Have you done any workout programs before?
Yes
No
Please specify which workout programs have you done?
When was the last time you have participated in physical fitness programs?
1 Month Ago
2 Months Ago
N/A
Other
How do you rate yourself in terms of fitness?
1
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
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Medical Information
Any allergic reaction to medicines (e.g. aspirin, penicillin, etc.)?
Please provide and explain.
Are you currently taking any prescribed medications?
Are you currently taking any prescribed medications?
Please provide the details and frequency of dosages. Enter N/A if none
Are you experiencing any epileptic seizures?
Please Select
Yes
No
Do you have Diabetes?
Please Select
Yes
No
Have you had any operation in the last two years?
Please Select
Yes
No
Please specify, which operation have you had?
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Disclaimer
Submit
Should be Empty: