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motivFIT Registration Form * Required

Thank you for registering for motivFIT's Fitness. Please submit the form below to complete the registration process. About You: *First Name *Last Name *Street Address *City *Email Address *State                    * Zip     Home Phone Work Phone Cell Phone Profession *Date of Birth *My main goal is: I rate my current fitness level a    1 2 3 4 5 6 7 8 9 10    (10 = very fit)     Emergency Contact Information: *Name *Phone Medical History: *1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes     No   *2. Do you feel pain in your chest when you perform physical activity?  Yes     No   *3. In the past month, have you had chest pain when you are not performing any physical activity? Yes     No   *4. Do you lose your balance because of dizziness or do you ever lose consciousness? Yes     No   *5. Do you have a bone or joint problem that could be made worse by   a change in your physical activity? Yes     No   *6. Is your doctor currently prescribing any medications for your blood pressure or for a heart condition? Yes     No   *7. Do you know of any other reason why you should not engage in physical activity? Yes     No    Describe:    If you have answered " Yes" to one or more of  the above questions, consult your physician before engaging in physical activity.  Tell your physician which questions you answered "Yes" to.  After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. *8. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? Yes     No     Describe: *10. Do you take any prescribed medication on a permanent or semi-permanent basis? Yes     No     Describe: *11. Do you have a seizure disorder (epilepsy)? Yes     No *12. Do you have diabetes Adult or Juvenile? Yes     No   Medication: *13. Have you ever been found to be anemic (low blood count)? Yes     No *14. Do you have High Blood Pressure (hypertension)? Yes     No   Medication: *15. Do you have or have you ever had the following diseases?                   Heart Disease:                   Lung Disease:                   Kidney Disease:                   Liver Disease: Yes     No Yes     No Yes     No Yes     No *16. Do you have asthma? Yes     No   Medication: *17. Have you ever had a severe neck injury? Yes     No      Describe: *18. Have you ever been knocked out? Yes     No      Describe: *19. Do you wear glasses or contact lenses? Yes     No *20. Have you had a broken bone or fracture in the past 2 years? Yes     No      Describe: *21. Have you ever injured your back? Yes     No      Describe: *22. Do you have back pain? Please Select Never Seldom Occasionally Frequently with vigorous exercise or heavy lifting *23. Have you had knee pain in the past 2 yrs that has disabled you longer than a week? Yes     No      Describe: *24. Do you have other physical conditions, which cause pain? Yes     No      Describe: *25. Detail any surgical procedures: *26. What are your goals for the next three months? *27. Have you had your body fat tested? Yes     No     If Yes, %:   *28. Are you training for a specific event? Yes     No      Describe: NOTICE: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program!    *** Please type "agree" in this box stating that you agree to and have read the ***  Consent & Release of Liability (PDF).  Viewing a PDF document requires the use of a special viewer. If you do not have Adobe Acrobat Reader, you may download it here.  Fitness Classes & Payment Information: I was referred by: Please specify publication / website / friend or other referral: Craig's List Google Goggle Sponsored Link motivFIT Blog Ask.com BING Yahoo AltaVista AllTheWeb AOL Backpage Facebook Exercise Friends Client of motivFIT Family / Friend T-Shirt Flyer Referal Other   Camp Locations  Date Spots Left Times FITNESS CAMPS MARCH  2010 CLASSES HENDERSON ( Anthem Hills Park ) Mar 1 - Mar 26 NOW REGISTERING 4 6:00am - 7:00am HENDERSON ( Anthem Hills Park ) Feb 1 - Feb 26 NOW REGISTERING 4 10:00am - 11:00am BODY BLAST WORKOUT *** HENDERSON ( Anthem Hills Park ) March 15 - March 26 CLOSED SOLD OUT! 6:00pm - 7:00pm FITNESS CAMPS APRIL  2010 CLASSES HENDERSON ( Anthem Hills Park ) Mar 29 - April 23 NOW REGISTERING 6 6:00am - 7:00am HENDERSON ( Anthem Hills Park ) Mar 29 - April 23 NOW REGISTERING 5 10:00am - 11:00am HENDERSON ( Anthem Hills Park ) Mar 29 - April 23 NOW REGISTERING 6 6:00PM - 7:00PM         I will be paying by:                    Check / Cash         Credit Card                                Please select Training Package:         Results Guaranteed Package    Get Fit Package     Body Blast                                                                                                               If you have a Promotional Code please enter it here:                                                                       We accept online credit card payments through PayPal or personal checks. Once you click submit you will have the option to pay online or if you prefer you will be provided with our mailing address for you payment. If you are registering for one of our Fitness Camps, you will receive detailed instructions in your Welcome Packet prior to your first day of Fitness Camp. Waiver must be signed prior to participation.  All registration forms and checks must be received at least 3 days prior to start of fitness classes to allow for processing.  Class sizes are limited to allow for more personalized training so be sure to register early. By clicking Submit, you are representing all information on this form is true and correct.                                                                                                                         3

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