Free Trial Registration Form
CONTACT DETAILS
Participant’s Full Name:
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First Name
Last Name
Sex:
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Male
Female
Age:
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Participant's Date of Birth:
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Month
-
Day
Year
Date
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant's Mobile Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Participant's Email:
Participant's Social Media:
Parent/Guardian’s Full Name:
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First Name
Last Name
Relationship to Participant:
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Parent/Guardian's Mobile Number:
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Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian's Email:
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Parent/Guardian's Social Media:
Please List Authorized Contacts in the Case of an Emergency (Name and Phone Number):
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EDUCATION
Participant's Current Grade:
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1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College
Other
Name of Current School:
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HEALTH QUESTIONNAIRE
Please list all past and current medical conditions:
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Please list all medications and supplements:
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Do you have any allergies? If yes, please list all your allergies (medicines, pollens, food, stinging insects, etc.):
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Have you ever had surgery? If yes, list all past surgical procedures.
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Has the doctor stated that you have a heart condition and/or you should only perform physical activity recommended by a physician?
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Yes
No
Do you feel discomfort, pain, tightness, or pressure in your chest when performing (or not performing) physical activity?
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Yes
No
Do you lose your balance because of dizziness? Or do you ever lose consciousness?
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Yes
No
Have you ever had a seizure?
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Yes
No
Do you have a bone, muscle, ligament, or joint injury that bothers you?
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Yes
No
Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
*
Yes
No
Do you cough, wheeze, or have difficulty breathing during or after exercise?
*
Yes
No
Do you know of any other reason why you should not engage in physical activity?
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Yes
No
If you answered "Yes" to any of the questions above, please provide an explanation below:
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ATHLETE PROFILE
Which sport(s) do you participate in?
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Football/Flag Football
Basketball
Baseball/Softball
Track & Field/XC
Soccer
Volleyball
Wrestling
Cheerleading/Gymnastics
None
Other
Goals:
REFERRAL
How did you hear about us?
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Google
Social Media (Instagram/Facebook)
School
Friend/Family Member/Colleague
TERMS & CONDITIONS
Parent/Guardian's Signature
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Participant's Signature
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Date
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Month
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Day
Year
Date
Hour Minutes
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PM
AM/PM Option
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