Get Fit Chilliwack 2012! Registration

Name*

FirstLast

Email*

Address*

Street AddressAddress Line 2CityProvincePostal Code

Primary Phone*

Secondary Phone

Date of Birth*

How Did You Hear About The Challenge?*

T-shirt size*

What is your personal goal for the next 6 weeks?

Questions or Comments?

PAR Q #1: Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

Yes
No

PAR Q #2: Do you feel pain in your chest when you do physical activity?*

Yes
No

PAR Q#3: In the past month, have you had chest pain when you were not doing physical activity?*

Yes
No

PAR Q #4: Do you lose your balance because of dizziness or do you ever lose consciousness?*

Yes
No

PAR Q #5: Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity?*

Yes
No

PAR Q #6: Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*

Yes
No

PAR Q #7: Do you know of any other reason why you should not do physical activity?*

Yes
No

IMPORTANT: I have carefully read and understood the Informed Consent, Waiver, and Release Agreement and I agree to the terms and conditions of the Informed Consent, Waiver, and Release Agreement. I understand that waiving certain legal rights by agreeing to the terms and conditions of the Informed Consent.*

I accept

If I answered 'yes' to any of the PAR Q questions, or am pregnant, I understand that I am required to get my doctor's approval for exercise prior to beginning the Challenge.*

I accept

I understand that any picture taken with Ascend Fitness is the property of Ascend Fitness and can be used at the discretion of Ascend Fitness. If I do not wish for my photo to be used, I will notify Ascend Fitness Coaching upon class registration.*

I accept

I certify that I am the person named above and that I am filling out and submitting this form on my own behalf and not on behalf of another person.*

I accept

Please select a payment method*

Please select your registration option:*

Total

$ 0.00 CAD

12% HST tax included in price

Yes! I am ready to get fit, increase my energy levels, get more muscle, and FEEL FANTASTIC!!!

Get Fit Chilliwack Challenge 2012

Ascend Fitness Boot Camp

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