Demo Class Registration
1. Personal Details
Please Provide the Needed Information of the Participant
Full Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date
Identity Number
*
Please provide a valid ID number
Gender
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Is the participant older than 18 years of age?
*
Yes
No
Full Name of Parent or Guardian
*
First Name
Last Name
Phone Number of Parent or Guardian
*
Please enter a valid phone number.
Format: (000) 000-0000.
Member or Parent Signature
*
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Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
2. Medical Information
Please Provide Needed Medical Information of the Participant
Do you have any allergies?
*
Yes
No
Please provide your allergy/s
*
Do you have any chronic conditions?
*
Yes
No
Please provide your chronic condition/s
*
Are you on any chronic medication?
*
Yes
No
Please provide your chronic medication/s
*
Do you currently have (or have had within the last 12 months) a bone, joint, or soft tissue injury?
*
Yes
No
Please elaborate regarding your injury
*
Have you been hospitalized within the last 12 months?
*
Yes
No
Please elaborate regarding your hospitalization
*
Have you ever undergone any medical operation/s other than what has already been indicated?
*
Yes
No
Please elaborate regarding the medical operation/s you have undergone
*
Has a doctor ever said that you should only do medically supervised physical activity?
*
Yes
No
Please elaborate
*
Do you suffer from chest pain at rest, during daily activity of living, or when you do physical activity?
*
Yes
No
Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?
*
Yes
No
Is there any chance that you might be pregnant?
*
Yes
No
Please indicate your trimester
*
1st Trimester
2nd Trimester
3rd Trimester
Member or Parent Signature
*
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Next
Preferred Time Slot
Please indicate your preferred time slot to attend a demo class
Appointment
*
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3. Emergency Contact
Please Provide the Needed Emergency Contact Information
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Individual
*
Please Select
Parent/Guardian
Spouse/Partner
Sibling
Family Member
Friend
Submit
Submit
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