Professional Documents
Culture Documents
Biggest Loser Registration
Biggest Loser Registration
Registration/Fitness Analysis
Name: ___________________________________________________ Emergency Contact: ____________________________ Date: _________
Phone #: _______________________
Registration Fee ($150 non-member/$120 monthly member) $_________ Paid on _________ Cash/Check
Indicate any diseases or illness you have had or currently have ______ Heart Problems ______ Heart Attack ______ Chest Pain or Angina ______ Bypass or angioplasty ______ Abnormal Stress Test or Irregular Heart Beat ______ High Blood Pressure ______ High Cholesterol ______ Diabetes Mellitus, if yes, are you insulin dependent? ______ ______ Stroke ______ Impaired Circulation ______ Asthma or other breathing problems/shortness of breath ______ Fatigue ______ Low Blood Pressure ______ Hernia ______ Chronic Back Problems ______ Arthritis ______ Muscular Limitations ______ Epilepsy or Seizures ______ Knee Pain ______ Shoulder Pain ______ Any other diseases or chronic conditions not mentioned, if yes, please explain _________________________________________________________________________________ ______ Are you currently taking any medications? If yes, what type/reason __________________________________________________________________________________ __________________________________________________________________________________ ______ Are you pregnant? ______ Do you currently exercise? If yes, how many times per week? ___________
HAVING READ, UNDERSTOOD, AND AGREED WITH THESE TERMS, I HAVE EXECUTED THIS RELEASE, TO BE EFFECTIVE IMMEDIATELY.
______________________________________________________ Applicant Signature If mailing, please remit registration and payment to: Studio 356 LLC 616 South Pike RD, Suite 202 Sarver, PA 16055 __________________ Date