CoachShellie Boot Camp Registration Form

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First Name *

Last Name *

Email Address *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Mobile Phone (Texting will be used to notify about any potential changes to class schedule or cancellations) *

Date of Birth *

YYYY

Height

Weight

Emergency Contact Name/Relationship *

Emergency Contact Phone Number *

How did you hear about us?

Option 1

Clear selection

If referred, by whom?

What are your specific fitness/health goals for boot camp? (Please, check all that apply.)

Increase strength and endurance

Improve cardiovascular fitness

Reduce body fat

Exercise regularly

Improve muscle tone

Reduce stress

Control blood pressure

Improve productivity

Lower cholesterol

Improve nutritional habits

Increase my health awareness

Feel better overall

Other:

PAR-Q

PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people, physical activity should not pose any problems or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these few questions. Please read them carefully and check YES or NO. If you answer yes, please explain.

Has your doctor ever said you have heart trouble? *

Yes

Do you frequently have pains in your heart and chest? *

Yes

Do you often feel faint or have spells of severe dizziness? *

Yes

Has a doctor ever said your blood pressure was too high? *

Yes

Has your doctor ever told you that you have a bone or joint problem(s), such as arthritis that has been aggravated by exercise, or might be made worse with exercise? *

Yes

Is there a good physical reason, not mentioned here, why you should not follow an activity program even if you wanted to? *

Yes

Are you over age 60 and not accustomed to vigorous exercise? *

Yes

Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness? *

Yes

Are you currently taking any medications? If YES, please specify in space provide below. *

Yes

Do you currently have a disability or a communicable disease? If YES, please specify in space provided below. *

Yes

For any YES answers, please use space provided below to explain.

Are you able to participate in physical activity?

If you answered NO to all questions above, it gives a general indication that you may participate in physical and aerobic fitness activities and/or fitness evaluation testing. The fact that you answered NO to the above questions is no guarantee that you will have a normal response to exercise. If you answered YES to any of the above questions, then you may need written permission from a physician before participating in physical and aerobic fitness activities and/or fitness evaluation testing.

By checking "I Agree", you agree to the Informed Consent Waiver/Release and Hold Harmless Agreement found at this link http://coachshellie.com/waiver/ *

I Agree

I Disagree

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