CHW Client Services Request Form

Client Services Request Form
Name*

First NameLast Name
Sex:*
YesNo
Employee ID
Cougar Card ID number (7 digits, ex. 0123456)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Best Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
MaleFemaleNo Preference
Please take a minute to fill out the Physical Activity Readiness Questionnaire (PAR-Q) below. The answers will ensure you are fit to train without seeking prior medical advice. Please read each question carefully and answer honestly – our primary aim is always HEALTH and performance.
YesNo
Please give a short explanation:
YesNo
Please give a short explanation:
YesNo
Please give a short explanation:
YesNo
Please give a short explanation:
YesNo
Please give a short explanation:
YesNo
Please list medications:
YesNo
Please give a short explanation:
If you have answered YES to any of the above questions, please seek medical advice before taking part in any physical activity.
In signing this document, you have stated that you are fit and healthy to train.
Date*

MonthDayYear
Email
example@example.com
Signature
Should be Empty: