Fitness Learning Center Registration Form

Today's Date *

Name *

First

Last Name *

Last

Class/Program you will be joining

Tai Chi

Yoga

Weight Loss Boot Camp

Strength Training

Personal Consultation

Private Gym

Meditation

Class Start Date MM/DD/YYYY *

Fitness Programs you may be interested in *

Tai Chi

Yoga

Weight Loss Boot Camp

Strength Training

Personal Consultation

Private Gym

Meditation

Email

Address Line 1 *

Address Line 2

City *

State *

Zip *

Birthday MM/DD/YYYY *

Primary Phone *

Type of Phone *

Home

Cell

Work

Home Phone

Cell Phone

Work Phone

Emergency Contact Person *

Emergency Contact Phone

Emergency Contact Person's Relationship to You *

For example, if your mother is the Emergency Contact Person, type in mother.

How did you hear about us? *

I have read and agreed to the Participant Release Statement written below *

Yes

No

PARTICIPANT RELEASE STATEMENT I understand and agree that there are risks, foreseeable and unpredictable, associated with any exercise program. I am aware of these risks and agree that my participation is at my own risk. If my application for the Tai Chi class, Yoga class, Strength Training class , and/or Exercise Machine use from Deoskar Integrative Health is accepted, and I am permitted to participate in this program, I hereby understand and agree that neither Deoskar Integrative Health nor any cosponsoring organization or facility, nor their respective chapters, officers, directors, employees, agents, members, or volunteers, shall assume or have any responsibility or liability for expenses or medical treatment or for compensation for any injury I may suffer during or resulting from my participation in this program. I do hereby, for myself, my heirs, executors, and administrators, waive, release, and forever discharge any and all rights and claims for damages that I may have or that may hereafter accrue to me arising out of or in any way connected with my participation in this or any future programs. I also represent and warrant that I have been advised to seek consultation from my doctor about whether I can safely participate in this program and whether there are precautions or limitations to my participation.

Fitness Learning Center Registration Form

MODIFIED PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)