Continuing Education Online Application

This form has been designed for credit/debit card and ACH (electronic check) payments.

If paying by insurance/3rd-party payment, it is recommended you either come
by the Fitness Office in room PE-2 in the gym OR call 405.422.6229 to enroll.

Name:

First NameMiddle NameLast Name

Date of Birth

Date

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Type:

Phone Number

Area CodePhone Number (xxx-xxxx)

Email address available?

Email:

example@gmail.com

Information Security Item #1

Please select a six-digit PIN - Redlands values the confidentiality of your information and includes this item to keep it securely.

Information Security Item #2

Please select a passphrase that may include numbers, letters, and/or symbols - Redlands values the confidentiality of your information and includes this item to keep it securely.

PAR-Q Questions:

Rows	Yes / No?
Has your doctor ever said that you have a heart condition and should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do a physical activity?
Have you had chest pain in the past month while not physically active?
Do you lose your balance because of dizziness, or do you ever lose consciousness?
Do you have a bone or joint problem that could e made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reasons you should not engage in physical activity?

If you answered "Yes" to any of the questions above, it is recommended that you consult with your healthcare provider before starting any physical activity.

Additionally, suppose you are over 40, inactive, or have other health concerns. In that case, it is also recommended that you consult with your healthcare provider before you begin any physical activity program.

It is also important to remember that physical activity is integral to a healthy lifestyle and can provide numerous health benefits, such as reducing the risk of chronic diseases, improving cardiovascular and musculoskeletal health, and promoting mental well-bring.

If you answered "No" to all of the questions above, it is generally safe for you to begin a physical activity program. However, it is still recommended that you start slowly and gradually increase the intensity and duration of your activity as your fitness level improves.

Physical Activity Waiver: I acknowledge that I have voluntarily chosen to participate in a program of physical exercise. I understand that there are risks involved in any physical activity. By signing and submitting this document, I assume all risk for my health and well-being by participating in any program offered by Redlands Fitness for Life. I cannot hold Fitness for Life, Redlands, and any employee of this facility responsible for any damages to me or my property.

Before enrolling in a Fitness for Life plan, please check the Redlands website for the Fitness Center hours by clicking HERE and then selecting the 'Facilities' tab. Please note that no one under the age of 16 is allowed in the Fitness Center.

All wellness classes meet on Mondays and Wednesdays from 10am to 11am unless otherwise noted. You may view descriptions, session numbers, and schedules for the wellness classes by clicking HERE and then selecting the 'Classes' tab.

Please indication the class type and session number in which you wish to enroll:

(Examples: "Session #3 of Chair Yoga" OR Cougar Strength Session #1)

Refund Policy: With written request, refunds are available prior to the start of the Fitness for Life membership or wellness class. No refund will be issued once a membership or class has started. Full refunds will be given for memberships or classes canceled by Redlands Community College. Please allow six weeks for refund processing.

How do you wish to pay for your enrollment?

My Products

Individual Fitness for Life for $75$75.00

Three (3) month membership

Quantity
Item subtotal:

Family Fitness for Life for $90$90.00

Three (3) month membership for family in home only

Quantity
Item subtotal:

Monthly Fitness for Life for $30$30.00

One month at a time membership

Quantity
Item subtotal:

Chair Yoga $30 . Before entering your payment information and clicking Submit, please ensure you have selected the session number in which you wish to enroll in the section above.

Chair Yoga $30 $30.00

Before entering your payment information and clicking Submit, please ensure you have selected the session number in which you wish to enroll in the section above.

Quantity
Item subtotal:

Cougar Strength $30. Before entering your payment information and clicking Submit, please ensure you have selected the session number in which you wish to enroll in the section above.

Cougar Strength $30$30.00

Before entering your payment information and clicking Submit, please ensure you have selected the session number in which you wish to enroll in the section above.

Quantity
Item subtotal:

Total $0.00

Payment Methods

Debit or Credit Card

ACH Bank Transfer

Please hand the tablet to the Fitness Team member assisting you.

Fitness Team member ONLY

Fitness Team Tember: please enter the information necessary for course enrollment and check/3rd party payment. then return tablet to client.

Date

Signature

I certify by signing on the line above that I wish to purchase the item(s) selected. Furthermore, I agree to all terms outlined in this document.

DRAFT Document - DO NOT SUBMIT YET - Redlands Community College Continuing Education Application for Wellness Classes & Fitness Facilities Access

Physical Activity Readiness Questionnaire (PAR-Q)

My Products