Fitness Center Sign Up/Waiver
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Do you currently or have you ever suffered from any of the following conditions? Please select if applicable
*
Heart Problems
Circulatory Problems
Blood Pressure problems
Joint, movement problems
Feel dizzy or imbalance during exercise
Currently Pregnant or recently given birth
N/A
Do you currently or have you ever suffered from any of the following conditions?
*
Back/Spinal pain
Headaches or migraines
Any recent surgeries
Currently being prescribed medication
Diabetes
Asthma or breathing problems
N/A
If you selected any of the previous conditions, please provide details. Or answer N/A if it does not apply.
*
Please select your status at CSM
*
CSM Staff or Faculty - Annual Membership
CSM Adjunct Faculty - Semester Based Membership
CSM Student - Semester Based Membership
Student/Employee ID
*
Are you interested in individual/group Personal Training? Group Fitness Classes?(Yoga/Spin) Intramural Sports (Basketball, Volleyball, Kickball, Dodgeball, Pickleball)
*
What are your fitness goals?
*
Lose weight
Improve overall health
Get in shape
Lift more weight
Gain muscle mass
Other
I understand that once I submit this form, CSM will confirm my eligibility. Once that is confirmed I will receive my key tag. I must show my key tag and check in and out via the CSM app. Passes will be issued by semester and are applicable to the active staff, faculty, or student only.
*
I understand
Submit
Should be Empty: