Your Name (required)

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Your Best Phone: Cell/Home/Office (required)

Emergency Contact (required)

Emergency Contact Phone (required)

Date of Birth 00/00/00 (required)

Age (required)

Height (required)

Weight (required)

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Your Occupation/Employer (required)

Do you have or have you had any pain or tightness in the front or back of your chest?
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Have you ever been told you have an abnormal EKG?
 Yes No

Does your heart ever beat irregularly?
 Yes No

Has your physician ever said you have a heart murmur?
 Yes No

Do you have troubles walking/jogging or in using your hips, shoulders or knees?
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Please list any past or present medical conditions and/or surgeries you have or have had (required)

Your Fitness Goals & Interest

What class are you interested in?

How did you hear about us?