Fitness Center Sign Up/Waiver

Fitness Center Sign Up/Waiver
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / 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 ProblemsCirculatory ProblemsBlood Pressure problemsJoint, movement problemsFeel dizzy or imbalance during exerciseCurrently Pregnant or recently given birthN/A
Do you currently or have you ever suffered from any of the following conditions?*

Back/Spinal painHeadaches or migrainesAny recent surgeriesCurrently being prescribed medicationDiabetesAsthma or breathing problemsN/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 MembershipCSM Adjunct Faculty - Semester Based MembershipCSM 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 weightImprove overall healthGet in shapeLift more weightGain muscle massOther
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
Should be Empty: